To give our readers an in-depth look into how clinical pathways are being implemented, Journal of Clinical Pathways (JCP) is launching Cancer Center Spotlight, a new feature that brings you inside pathways programs at top cancer centers around the United States. We profile clinical pathways teams and cancer center leadership to gain a better understanding of how and why they use clinical pathways in their facilities; how their infrastructure and staff support pathways use; how the data captured by pathways is used for reporting and measurement; and how their pathways are evolving.
Our first installment features Moffitt Cancer Center in Tampa, FL. Moffitt is the state’s largest clinical cancer research unit with more than 450 clinical trials and is nationally ranked as a top 10 cancer hospital by US News & World Report. Moffitt’s clinical pathways are provider-developed and fully maintained and updated in-house through their pathways team members and faculty. Built on Moffitt’s core multidisciplinary values, their pathways, regardless of disease type, span across departments and integrate referrals and input from specialists throughout the cancer center. They have currently integrated 17 of their 56 clinical pathways into their electronic health record system for better physician access at the point of care, and their payer strategies team is working with payers toward leveraging their pathways to reduce the number of prior authorizations needed.
One of the people we spoke with was Jack Kolosky, CPA, MBA, chief operating officer, Moffitt Cancer Center, who gave us an inside look at Moffitt’s mission, research vision, and pathways program today and for the future.
The full Cancer Center Spotlight on Moffitt’s pathway program will soon be available.
As chief operating officer and executive president, what are your day-to-day responsibilities related to the Cancer Center?
My responsibilities are mostly regarding the clinical operations of the hospital, which is 80% or so of the overall institutional revenues and net income. The heart and soul of what Moffitt does is research, and I support that in various ways but most often through activities supporting and facilitating our clinical trials. I try to ensure that our clinical operations are in line with Moffitt’s overall mission.
Moffitt is a relatively young organization, and I think there is good and bad about that. The good is that we are not bound to the way things have always been done in the past. For example, from the start, we have been organized into multidisciplinary care teams and departments, which is not typically the way it’s done in other academic centers. I think this is a strength because that interdisciplinary model enables our people—medical oncologists, surgeons, radiation, radiologists, pathologists, support teams, nursing and social work, etc—to work together easily in clinical teams. It allows them to better focus on the needs surrounding an individual patient.
We’ve grown substantially since our beginnings, but I would say that our outcomes are superior, in part, because of our clinical interdisciplinary team model. But it is also due to the proficiency of our faculty in general and how we have developed and utilized tools like clinical pathways to focus our treatment plans on the best available evidence to produce the best outcomes.
We try to thoughtfully take a look at what we think is the future state of affairs and be responsive to them in terms of what direction we are going, how our pathways should be evolving, the innovative contracting that we’ve tried to do with managed care plans, etc. We try to think more broadly about population health and the overall care experience across the entire episode from diagnosis to survivorship. Again, I think because of our organization’s relative youth and because of our relative size, we’re probably much more nimble than some of other organizations to do some of these things; they just have a large, large ship to turn around, and it’s much easier said than done. Moffitt is a little bit smaller and lighter—growing certainly, but nonetheless, unified around a pretty good mission and leadership focus.
What initiatives is Moffitt focused on going into 2019?
Right now, our initiatives are really in their early stages. But we plan to continue on with some of the programs we have seen success with, pathways being the core. We are working on incorporating pathways into our contracting processes, getting rid of some of the things that most faculty or staff find to be a burden and that is wasteful, such as pre-authorizations.
I think our future will be market expansion—how do we bring the Moffitt brand of care to more communities and more people, make it more accessible? If we really believe that Moffitt care is the best, why shouldn’t it be available to everybody? Not everybody is going to use it, but we can at least make it available to everyone. The fact that we’re centrally located in Tampa creates a burden to people who live far away, whether it be throughout the state of Florida or beyond.
We are also thinking through potential digital opportunities, like apps that can be put on smart phones or just better ways that we can communicate with patients or caregivers, using the data that we have and really developing more artificial intelligence around that. We’ve talked about some cutting-edge things like digital pathology that that we may be investing in and not just scanning the images but learning from those images as to what’s the best diagnosis in light of that data. We’re not there yet, but we can see where we can get there from here. So that would be the second focus or initiative we have in mind.
And then a third one is around personalized medicine. What makes my genetic makeup different than yours and how can we better treat you as an individual as opposed to just a diagnosis of whatever disease it happens to be? There is great opportunity to refine diagnosis using this information—a much greater opportunity to provide more personalized medicine. This also includes things like immunotherapy: how do we use the body’s own defenses to fight disease through treatments like CAR-T therapy? Tumor-infiltrating lymphocyte or TIL therapy is another therapy that’s coming down the road too. We see great opportunities in these therapies, and Moffitt, as an organization, has invested in these things through research and, clinically, in the expansion of programs because we think these are the future.
We understand that Moffitt has an excellent CAR-T delivery program. Can you tell us a bit more about the CAR-T program?
If we’re not the leader, we are one of the leaders in the CAR-T area—top three or so in terms of numbers of patients we have delivered standard of care on CAR-T. The bad news, unfortunately, is that Medicare hasn’t clearly set out a protocol for payment of CAR-T yet, so we’re kind of funding it at this point until Medicare figures that out. The good news is that the measurable results and improvement of care for patients is really outstanding. Our heads of research really see the value in this sort of therapy, so we have tried to invest in the faculty, staff, and the subtleties and such to support CAR-T. We are also continuing to develop support surrounding other immunotherapy types using the body’s own defenses.
Going back to our discussion of pathways, how does Moffitt—whether in their pathways or in their care in general—balance the need for personalized medicine as well as standardized care?
The Moffitt pathways are really quite granular. For instance, even starting at diagnosis—the pathway doesn’t just assume that there is a diagnosis and then there is chemotherapy. Before the pathway begins, we think about what are those diagnostic tests or procedures that we need to do to better identify what that patient’s cancer is, so the pathway includes a prompt for the molecular tests, etc, that we would need to do, and there’s a sequence often that needs to happen after that. I’m not aware of any other pathways that do that sort of thing. We include so much detail into the pathway, especially in some disease states where we know that a path gets into those genetic markers; it’s already developed into the pathway at that lower level detail and accounted for. We also always try to incorporate any available clinical trials into the pathways as a potential option. Those are two differentiators that Moffitt has in our pathways based on what we have seen in others’ pathway programs: the granularity and the constant updating of new clinical trials on the pathways options.
Earlier, you talked about making Moffitt’s care more accessible. What would that look like in practice? We’ve heard talk about some institutions making their pathways openly available to other institutions who want to use them. Is that what you mean by increasing access?
Well that’s complicated. It’s similar to one football team handing over their playbook to another team, but maybe the second team doesn’t have the resources or personnel or structure to execute the first team’s plays. The second team may not be organized in a way that makes those plays work, or they’re not coached that way, etc. So, while we’re not necessarily completely opposed to that type of sharing, there’s a Moffitt way of doing things that makes it a little bit different. Not everybody is organized from the ground up as a multidisciplinary organization. And so, the fact is that they don’t even have a team on the field that is unified in that respect. Without having that integrated, interdisciplinary structure, it’s difficult to provide that type of unified care where people are working together as a team, consulting across disciplines and departments, and coming up with the best plan for a patient. Our faculty have zero incentive for saying, “Hold on, I’m doing surgery first, so I’m going to get the money for that.” They’re doing things for the right reasons for the betterment of the patient.