Health care has been traditionally immune to disruptive market forces until the COVID-19 global pandemic in 2020. This pandemic also highlighted the challenges and failings of our current health care system, creating the impetus for transformational system changes. Cancer care has been disproportionately impacted by this pandemic, from preventive care to treatment and patient follow-up, which may lead to later-stage cancers for patients and increasing patient morbidity and mortality as well as regression in the strides made in cancer care and overall patient survival. The oncology ecosystem is determined to do all it can to not only prevent these regressions but also to accelerate further advancements. This column outlines 10 observed trends and developments to further optimize cancer care in 2021 and beyond.
Historically, health care has been immune to disruptive market forces; however, 2020 no doubt will be viewed as a year that brought significant disruption to the US and global health care ecosystem. The COVID-19 pandemic highlighted the disparities and fragmentation of our health care ecosystem as well as the weakness of our care delivery models and payment systems. At the same time, the pandemic has become a catalyst for the widespread and rapid adoption of strategies that had been in the wings, such as telemedicine, virtual care, and new payment models, in addition to cross-collaborations that likely would have taken years to implement.
In the world of health care, COVID-19 has disproportionately affected patients with cancer. These patients have experienced significant declines in cancer screenings, biopsies, surgeries, and office visits, with delays in diagnosis and initiation of prescribed therapies, potentially leading to later-stage cancers and thus increasing morbidity and mortality. Patients are indirectly affected by a disruption in cancer research also.1,2 With continued waves of this pandemic, providers are worried about seeing retrogression in the incredible advancements that have been made in cancer care over the last few decades—such great strides as improved overall survival and death rates going down due to clinician care practices and skill sets; better understanding of the pathophysiology of cancer and heterogeneity of tumors; development of new therapies, new procedures, and biomarker testing; implementation of new care delivery models focused on quality, cost, and care coordination; and leveraging technology and big data for patient segmentation, among many other contributing factors.
In the past several years, there has been an increased focus on improving the quality of cancer care while reducing the total cost of care and the financial burden on patients and the health system. Efforts have included leveraging new payment models, new therapy combinations, reducing variation in care, embracing virtual care and education, addressing health care disparities, and placing an increased focus on real-world evidence, to name a few. The pandemic has accelerated these trends, some with super speed. Below are 10 trends, entrants, and developments (TEDs) that will contribute to the further optimization of cancer care in 2021 and beyond.
TEDs in Oncology to Optimize Cancer Care
1. New Therapy Combinations
Recent advancements in drug therapies to treat various types of cancer are truly incredible, for example, bispecific monoclonal antibodies, cancer vaccines, immunotherapies, next-generation biotherapeutics, oncolytic viruses, and targeted therapies. These therapies have contributed to improving the overall survival rates of patients with cancer.3
To achieve even greater efficacy of these therapies, researchers and manufacturers are working on combination regimens and augmenting therapies designed to boost low response rates, as well as identifying factors that could be contributing to or causing low response rates or acquired resistance to therapies.
2. Leveraging New Payment Models
As a means to improve the cost-effectiveness of cancer care in the private and public sectors, health systems, payers, and provider groups are increasingly experimenting with oncology
value-based payment models. These models include the Centers for Medicare & Medicaid Services’ Center for Medicare & Medicaid Innovation Oncology Care Model practices, accountable care organizations, and several commercial oncology models, each with incentive measures and performance targets to demonstrate improved outcomes and reduction in costs. Most have clinical and quality targets such as improvements in admissions/readmissions, emergency room visits, hospice care, and pathway compliance; patient satisfaction targets with an increased focus on patient reported outcomes and experiences; and cost targets such as lowering the total cost of care, drug utilization, shared savings risks, sites of care, and episodes of care.4
Amid the COVID-19 pandemic, some traditional fee-for-service practices are exploring alternative payment models as they acknowledge the ongoing shift from volume to value and the alternative revenue stream from these models.5 Additionally, some models incorporate a risk share component to providers for not meeting their clinical, quality, and cost targets.
3. Personalized Care
Cancer care continues to shift away from “one-size-fits-all” treatments, as molecular pathology has become fundamental to informing tumor diagnosis, prognosis, and therapeutic decisions. Identifying biomarkers to more effectively predict the right therapies and regimens for the right patients has become the standard of care.
Leveraging next-generation sequencing technologies for these biomarker tests and other tumor molecular profiling programs, we will continue to see increasing numbers of patients responding to regimens that have been personalized to their molecular pathology and genetics. This precision in patient-therapy matching and access to testing will further yield significant survival benefits derived from biomarker matching therapies in several cancer types.6 The collaboration between Foundation Medicine and OneOncology is an example of a strategic partnership to use real-world clinical and genomics data to improve access to genomic profiling and personalized medicine in community oncology practices across the United States.7
4. Health Care Disparities
With the continued increase in the costs of cancer care, certain subgroups of the population, including the young, lower income, and minority patients, have less access to the advancements in cancer care and are more predisposed to financial toxicity and/or bankruptcy as a result of treatment. The issues of historic health care disparities in cancer care have become even more acute with the COVID-19 pandemic, including a higher risk of acquiring COVID-19, a greater likelihood of hospitalization, and lower use of telemedicine.
Many organizations are now exploring opportunities to address these gaps by addressing housing, food, and other social determinants of health and adding these determinants to a patient’s health history for ongoing evaluation.8 They are also partnering with their networks to improve access to telehealth and broadband to conduct video visits and increasing providers’ and teams’ awareness of implicit biases and disparities in health care.9 We have started to see partnering with communities to educate patients and the building of a foundation for a diverse health care workforce. Similarly, health care policies are starting to be created or modified through the lens of achieving racial justice and health equity.8 All these efforts are an attempt to close disparities, improve access, and optimize cancer care for all populations.
5. Reducing Variation in Care
Unwarranted variation in care and clinical practice accounts for a significant amount of waste and costs in the system. Practices and organizations are increasingly addressing unwarranted clinical variation in oncology to ensure consistent levels of high-quality care while addressing cost-effectiveness.10 Some efforts being employed include the adoption of clinical pathways, evidence-based guidelines, and technology. For example, Flatiron Health has worked with community oncology practices to identify unwarranted variation in care, and CVS Health has launched a new oncology care program that leverages clinical pathways, technology, and genomic science to help bring consistency and successful practices to cancer care, improve patient outcomes, and lower overall costs.11
6. Virtual Technology Care and Education
Almost overnight, COVID-19 became the catalyst for virtual technology adoption across the health care system. Virtual health, including telehealth, digital therapeutics, navigation of care, meeting platforms, and educational resources, are here to stay in one form or another. At Texas Oncology, for example, telemedicine is now one of the permanent ways patient care delivery has shifted to facilitate patient-physicians communication. Physicians and teams are able to provide consultation, do follow-up visits and toxicity checks, patient education, and genetic counseling. Kaiser Permanente Northern California has transitioned aspects of the following services to telehealth: clinical visits and consultations, evaluations, supportive care, palliative care, and patient education and self-management.12,13 While some evaluations such as body scans must be completed in person, many patient care components can be done via telehealth. The focus is now on scalability (especially in rural and lower income areas), sustainability, appropriate reimbursement, and optimizing the balance between live and virtual in-person health care to improve access and overall care.
7. Analytics, Machine Learning, and AI
Health systems are increasingly working with internal or external analytic partners to combine data, analytics, and machine learning (and in a few cases, artificial intelligence [AI]), to optimize and transform cancer care by identifying medical utilization patterns, proactively predicting anticipated lines of therapy transition, identifying target populations for treatment, identifying unwarranted variations in care, cost savings opportunities, and much more. For example, Hackensack Meridian Health and data analytics partner COTA have tracked the various regimens and methods used for breast cancer treatment; based on their analysis, they have narrowed which treatment works best overall in specific patients, identified unwarranted variations in care, saved 20% on total spend, and improved patient outcomes.14 Health systems are working with entities like Flatiron and many other analytics/AI companies to unlock electronic health records and other patient data sources to develop real-world evidence (RWE) and actionable insights to improve cancer care and, eventually, find a cure for cancer while saving billions of dollars.15
8. Real-World Evidence
Real-world data (RWD) and RWE are increasingly being captured and used in oncology due to the growing recognition that randomized controlled trials (RCTs) are not always representative of the entire patient population affected by specific cancers. With the increased recognition from the Food and Drug Administration, RWE and RWD can complement RCTs, increasing understanding of cancer management and facilitating cancer treatment decisions for patients in the real world.16
9. Addressing Medication Management
As the complexity in oncology therapy management increases, (eg, combination therapies, gene therapies, and the increased use of oral oncolytics) adverse events from nonadherence, drug interactions and duplications, lack of education and knowledge, lack of affordability, and poor medication safety practices are on the rise. Clinical pharmacists and care managers are leveraging the American Society of Clinical Oncology (ASCO)17 and Community Oncology Pharmacy Association18 medication management tools and resources, as well as tools such as the Medication A.R.E.A.S. Bundle Handbook,19 that address medication management focusing on Adherence, Reconciliation, Education, Affordability, and Safe medication practices for pharmacists and care management. They are able to use these and similar resources20,21 to work closely with their patients to address barriers and individualize patient therapy solutions.
10. Legislative Policies and Societies
Now more than ever legislative and policy actions at the federal and state levels are shaping cancer care and the practice of oncology. This includes policies and executive orders impacting drug costs, new value-based payment models, and the 2021 Medicare Physician Fee Schedule and the Hospital Outpatient Prospective Payment System final rules. With administration and bipartisan support for some initiatives, there will most likely be additional regulatory and legislative changes that will continue to impact oncology. Having input from the Community Oncology Alliance, the Association of Community Cancer Centers, the ASCO oncology state societies, and other stakeholders will be critical to ensure these policies support the best quality of care for patients, caregivers, practitioners, teams, and the practice of oncology.
These 10 TEDs will make a major impact in optimizing the quality, care, and costs of oncology treatment as we bring key stakeholders from providers and staff, to payers, policymakers, pharmaceutical manufacturers, support services, and others across the health care continuum together to look at ways to turn the adverse impacts of this pandemic into a catalytic vehicle. Leveraging these current and new trends, welcoming new entrants, and embracing existing and new drivers to optimize cancer care delivery will make the quadruple aim of better care, smarter spending, healthier populations and communities, powered by resilient and high performing teams, a reality for all in oncology.
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11. CVS Health launches transform oncology care program to help improve patient outcomes and lower overall costs. CVS Health. December 12, 2019. Accessed January 28, 2021. https://cvshealth.com/news-and-insights/press-releases/cvs-health-launches-transform-oncology-care-program-to-help
12. Dr. Lakshmi Balasubramanian: cancer does not pause during COVID-19. Texas Oncology. July 16, 2020. Accessed January 28, 2021. https://www.texasoncology.com/who-we-are/news/2020/cancer-pause-covid19
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14. Morse S. Physicians build bundled payments system for breast cancer. Healthcare IT News. January 22, 2018. Accessed January 28, 2021. https://www.healthcareitnews.com/news/physicians-build-bundled-payments-system-breast-cancer
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18. Community Oncology Pharmacy Association. Resources. Accessed January 28, 2021. https://coapharmacy.com/patients/
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20. Agency for Healthcare Research and Quality. Medication Management Strategy: Intervention. Updated December 2017. Accessed February 9, 2021. https://www.ahrq.gov/patient-safety/reports/engage/interventions/medmanage.html
21. Food and Drug Administration. Educational Resources: Ensuring Safe Use of Medicine. Updated March 5, 2018. Accessed February 9, 2021. https://www.fda.gov/drugs/resources-you-drugs/educational-resources-ensuring-safe-use-medicine