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NCCN Roundtable Considers Challenges in Optimal Care for Patients: Who Decides?

In recent years, the factors that have contributed to decision-making for the treatment of cancer have become increasingly complex. Tumor-specific biology, the role of government and payors, and the management of end-of-life care, to name a few, have created a spectrum of new challenges relative to decision-making for clinicians and patients alike.

An expert panel at the NCCN 17th Annual Conference discussed the current landscape of decision-making in cancer care, the influence of payors on those decisions, and how these factors impact patients.

Moderated by Clifford Goodman, PhD, of The Lewin Group, the panel included: Karen Alban, RN, BSN, OCN, Oncology Nursing Society; Al B. Benson III, MD, Robert H. Lurie Comprehensive Cancer Center of Northwestern University; Nancy Davenport-Ennis, National Patient Advocate Foundation; Scott Gottlieb, MD, American Enterprise Institute; Shari M. Ling, MD, Centers for Medicare & Medicaid Services (CMS); Ray Lynch, CPA, MBA, Huntsman Cancer Hospital; Lee N. Newcomer, MD, MHA, UnitedHealthcare; and David G. Pfister, MD, Memorial Sloan-Kettering Cancer Center.

"The locus of decision-making has changed," said Dr. Goodman. "It is not just the clinician, the patient, and the family member in the exam room." He asked the panel whether or not the "center of gravity of patient-care decisions" is indeed shifting with a different emphasis and with different folks involved.

Ms. Davenport-Ennis responded that the payor community is now very involved in the decision-making. "Often, the very protocol that is going to be discussed for intervention with that patient may be impacted by the type of insurance product that they have," she said.

Also considered was the impact the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) and commercial pathways have on decision-making and the delivery of optimal care. Dr. Goodman asked, "Aren't guidelines and pathways supposed to present options, share information, and provide a way to optimize care within a paying structure?"

Dr. Newcomer responded that guidelines are simply advisory – but that they are from what we know from outcomes today, the best recommended treatments. He explained that current adherence to guidelines is "not that good," but that, "If we pay better attention to the guidelines, we would not be wasting money; this would be optimum care."

Mr. Lynch concurred that one could define quality of optimum care as adherence to the standard of care, and that the standard of care is indeed the NCCN Guidelines®. He further stated that he would like to see outcomes play a larger role in the measurement of quality care. Dr. Ling agreed, asserting that there is a need to develop reliable and consistent data sources that will then provide the basis for evaluating quality of care by outcomes.

Dr. Goodman challenged the panel to "flash forward" five years and identify critical factors that will change the way optimal care is defined and treatment decisions are made.

Ms. Alban predicted that survivorship care plans will be better defined. Future care plans "will help direct us and direct those patients who are survivors long term." She further stated that end-of-life planning needs to be part and parcel of the plans for those patients who aren't expected to live an extended life.

Dr. Benson responded that oncology is increasingly becoming a field in which personalized medicine is necessary and important, but this presents a challenge for clinicians. In order to make the decision process more effective, he said, clinicians will need to have an understanding of tumor biology in order to identify specific therapies for specific patients.

Dr. Gottlieb spoke to a different challenge clinicians are facing:  There will be a shift of power away from individual doctors making decisions to payors and hospitals, he said. "Within five years, about 80 percent of oncologists in this country will be working for hospitals or health plans." Moreover, he predicts that the government is going to impose more control over utilization and reimburse for the lowest cost option in what they consider to be interchangeable treatments.

From the government perspective, Dr. Ling said that she foresees "a convergence and a closer collaboration that will build the data sources of the outcomes so that we can use the information to more effectively improve on quality and drive the system toward optimal outcomes for patients and beneficiaries."

Dr. Pfister said, "There will continue to be a focus on guidelines and pathways, which I think will increase." He predicted that the rigor and development process will continue to become more rigorous, and that value will become a consideration.

Dr. Newcomer agreed that value is an important consideration. He asserted that there is an urgent and overdue need to rid the current system of things of little or no value. "By 2017, if we haven't come to a decision about what we can prune out of the system, we are on a flight path for a crisis," he said. "We have to do it now; five years will be too late." He predicts that within the next 18 years, insurance premiums will exceed the average income in the United States.

"The locus has changed," said Dr. Goodman in closing. "The five-year scenario is something on which we need to start now."