The Birth and Future of Quality Initiatives in Oncology

Joseph Simone, MD

President, Simone Consulting

Session Objective:

At the end of this session, participants should be able to:

–Describe at least one measure on how the quality of cancer care

has been assessed nationally

–Describe at least one recommendation by the IOM and the

National Cancer Policy Board to improve oncology care

The Modern Quality Movement in Oncology

• Origins – Institute of Medicine

• Convincing ASCO to support QOPI

• First Steps -- National Initiative on Cancer Care Quality

(ASCO), QOPI (ASCO), National Surgical Quality Improvement

Program (ACS), National Cancer Database (ACS)

• Today

• The Future

National Cancer Policy Board

• Established in March 1997

• Housed at the Institute of Medicine and National

Research Council

• 20 members--consumers, providers, researchers

(e.g. Bob Young, Bob Day, Kathy Foley, Ellen

Stovall, Fran Visco, Bill McGuire, Joe Simone)

Purpose of Board

Policy research, findings and

recommendations to improve prevention,

control, diagnosis, and treatment of

cancer

Purpose of Board

Propose solutions to problems faced

in the nation’s battle against cancer

Ensuring Quality

Cancer Care

NATIONAL CANCER POLICY

BOARD

Ensuring Quality Cancer Care

1. What is the cancer care “system” and is it working?

2. What is quality cancer care and how is it measured?

3. What are the main problems and what steps can be taken to

improve care?

4. How can we improve what we

know about the quality of cancer care?

5. What steps can be taken to overcome barriers to access to

quality cancer care?

State of the Cancer Care “System”

For many Americans with cancer, there is a

wide gulf between the ideal and the reality,

between what is known and the health care

they receive.

Problems Evident in Cancer Care Quality

“Based on the best available evidence,

some individuals with cancer do not

receive care known to be effective for

their condition. The magnitude of the

problem is not known, but the National

Cancer Policy Board believes it is

substantial.”

Examples of Quality Problems

• Underuse of screening tests

• Lack of adherence to standards for diagnosis--inadequate biopsies, poor reporting of pathology studies

• Inadequate patient counseling regarding treatment options

• Underuse of radiation therapy and adjuvant chemotherapy after surgery

Improving Care

Ensure that patients undergoing procedures that are

technically difficult to perform and have been

associated with higher mortality in lower-volume

settings receive care at facilities with extensive

experience (i.e., high-volume facilities)

RECOMMENDATION 1

Improving Care

Use systematically developed guidelines

based on the best available evidence for

prevention, diagnosis, treatment, and

palliative care

RECOMMENDATION 2

Improving Care

Measure and monitor the quality of care

using a core set of quality measures.

RECOMMENDATION 3

Cancer Care Measures Should:

• Span the continuum of cancer care

• Be developed through a coordinated public–private effort

• Be used to hold providers accountable

• Be required of the Medicare and Medicaid programs

• Be disseminated widely

Ensure the following elements of quality care for

each individual with cancer:• Recommendations about initial management, critical to

long-term outcome, made by experienced professionals

• An agreed-upon care plan that outlines goals of care

• Access to the full complement of resources necessary to implement the care plan

RECOMMENDATION 4

Ensure the following elements of quality care for

each individual with cancer: • Access to high quality clinical trials

• Policies to ensure full disclosure of information about appropriate treatment options

• A mechanism to coordinate services

• Psychosocial support services and compassionate care

RECOMMENDATION 4 (CONT.)

Improving Care

Ensure quality of care at the end of life,

in particular, the management of

cancer-related pain and timely referral to

palliative and hospice care

RECOMMENDATION 5

Improving What We Know

A cancer data system is needed that can

provide quality benchmarks for use by

systems of care (such as hospitals,

provider groups, and managed care

systems).

RECOMMENDATION 7

Overcoming Barriers to Access

Services for the un- and under-insured

need to be enhanced to assure entry to,

and equitable treatment within, the cancer

care system.

RECOMMENDATION 9

Influential Policy Reports by the Institute of Medicine

“Ensuring Quality Cancer Care” (1999)

“Enhancing Data Systems to Improve the Quality of Cancer Care” (2000)

“Crossing the Quality Chasm” (2001)

ASCO Quality Care InitiativeBackground

Quality care a growing issue; forces growing to regulate quality

ASCO had already invested in NICCQ

NICCQ is a biopsy, not therapy

ASCO uniquely suited to lead a long-term program in quality cancer care

Why? Clinton health plan 1992 led to NCCN

IOM report on shortcomings in quality of cancer care 1999

Medicare Modernization Act 2002-3 led to decreased reimbursement…and embarrassing behavior by some

oncologists QOPI

Joseph Simone, MD

Quality of Care: Why Now?Key Influences

Societal

Economic

Public Policy

Professional

Quality of Care in Oncology:Societal Influences

More knowledgeable patients, families (though not as extensive as touted)

Profusion of internet sources of information (some good, some not)

Patient advocacy groups (some effective and helpful, some not)

Quality of Care in Oncology:Economic Influences

Payers (e.g.,UnitedHealth for BMT) and employers (Leapfrog Group) have quality of care programs that are expanding

Payers include “value” in assessing quality, e.g., cost and need, as well as medical excellence

“Cost and quality data will become public.” Robert Galvin, MD, Director of Corporate Healthcare, General Electric

Economic InfluencesNow and in Future

Medicare reducing reimbursement; fee-for-service often follows

Now are 4 workers per retiree; in 2020, 2 workers per retiree

Therefore Medicare taxes must go up or benefits must go down

Co-pays will riseMore employers don’t offer health

insurance

ASCO Quality Care InitiativeMember Barriers

Inertia- “too hard; too expensive” Denial- “I already give high

quality care” Fear of policing, public

judgment, inappropriate use of data for competitive advantage, possible loss of income

ASCO Quality Care InitiativePotential ASCO Barriers

ASCO treats as a short-term fad“ASCO not suited to changing

behavior, running complex, long term program”

Changes in program leadership, ASCO leadership support

Cost

The Quality Movement: Healthcare Systems

Kaiser-Permanente

Puget Sound, Virginia Mason

VA electronic medical record system

Intermountain HealthCare in Utah

Value of QOPI to Oncologists

Intrinsic value (the “right thing” to do) for many, not all

Curiosity and competitive nature of docsNetworking, toolbox for improvement, data

useful for businessRecertification - participation meets ABIM

performance improvement (part IV) requirements of maintenance of certification, Part IV now mandatory for oncologists

Will QOPI participation be required (or premium paid) by certain health plans?

QOPI: Operational Principles

Practice level system Presume that a faulty system is

responsible for most poor care; like fixing medication errors (“no fault”)

Avoid blame, public disclosurePresume docs respond to data they can

compare to other practicesProvide tools for improvement

QOPI Results Through Fall 2011

746 practices registered, 1,000+ sites 250-300 practices submit data each time 100+ quality measures 23,397 charts reviewed in this round 45 states represented 14 fellowship programs submitted data

from 1,000+ charts

Future of Quality Efforts in Oncology

Increasing focus on “value,” financial as well as clinical

Eventually, reports on patient outcomes will be required and published

Accountable Care Organizations will build quality and outcome measures into their systems (many $$ at stake)

Gradually, reimbursement will be heavily influenced by quality

Future of Quality Efforts in Oncology-2

Guidelines will become more sophisticated and more imperative

Increasing investment in EMR, downloading data daily or weekly for analysis re cost and appropriateness, thus fewer degrees of freedom for MD

In fact, adult oncology will begin looking a lot like pediatric oncology

Pediatric Oncology

50-90% on clinical trials, so… Guidelines for all: path, surgery, chemo, follow-up, all standardizedOutcomes measuredSelf-examination ➨ steps for

improvementResults reported and compared

Pediatric Oncology

Cure rate of childhood acute leukemia: 1962=0; 1975= 40%; 2004 ≅ 80%; 2011 ≅ 90%

No new frontline chemo agents since 1973!

Systematic trial and error can work if well-planned, transparent

Bonus: basic standards applied to all patients, on protocol or not

Future of Oncologists-1

Small practices will be even more handicapped in responding to data needs, thus increasing the MD movement toward employment (now over half of MDs)

New types of alliances and structures will emerge in oncology care, e.g. closed staff community hospitals, more academic “Lite” activity in community health systems

Future of Oncologists-2

Continued change in public view of doctors toward “skilled businessmen,” like lawyers

For some, fewer work hours For many, lower income Oncologists will continue to make a good

living (1st to 5th %ile of national income)