Practical Tips for Oncology Professionals Working in Value-Based Healthcare Systems

Practical Tips for Oncology Professionals Working in Value-Based Healthcare Systems such as Managed Care Organizations

Medicare Advantage programs, along with other similar managed care insurance plans, have become increasingly popular nowadays for senior members, due to their affordable premiums, expanded coverage of healthcare services, and accessibility in the community close to home. However, these programs can only be financially sustainable if they keep the healthcare costs and utilization low. This situation frustrates many oncology providers, as the high costs of cancer care often become the targets for cost-saving tactics such as pre-authorization, request denials, peer-to-peer reviews, coverage limitations, etc., that can jeopardize the care of people with cancer. For example, according to a survey by ASCO in 2022, nearly all oncology providers reported that pre-authorization caused delays and harms in patient care.¹American Society of Clinical Oncology. Nearly All Oncology Providers Report Prior Authorization Causing Delayed Care, Other Patient Harms. November 22, 2022. Viewed November 11, 2024. In addition, bureaucratic paperwork burdens are among the top reasons for burnout in the cancer care profession.²Duska, LR. When paperwork leads to burnout. ASCO Connection. July 14, 2017. Viewed November 11, 2024.

As an integrative oncologist who has been primarily serving patients in the managed care setting, I would like to provide some practical advice for any oncology professionals who are working in similar situations.

• First and foremost, establish a good working relationship with the managed care leadership team, such as medical directors, and don’t be antagonistic with them. Let them know that you are part of their team and interested and willing to learn about value-based cancer care, which is a term used to describe cancer care that is cost-effective, high-quality, and accessible.³Value-based Cancer Care. Viewed November 11, 2024. You will serve as a liaison on the front line to help them manage costs, but at the same time, also make it clear that you need to do what is best for the patients. It is a fine balance that is challenging but achievable. Your goal is to help the cancer care delivery system save money by providing appropriate care, not depriving patient care. When you position yourself this way, management is more likely to work with you in a collegial and friendly fashion.
• Be flexible and adaptable and understand that there are many ways to do things. The way that you are accustomed to is often not the only way, and may actually not be the best way. When working within limitations of managed care, try to be creative, think outside of the box, and find compromising solutions that benefit all stakeholders in the cancer care ecosystem, including patients, insurers, medical groups, and yourself.
• Develop a patient-centered practice style. One way to cut down cancer care costs is to make sure you provide the right treatments to the right patients at the right time in the right place. It goes beyond just simply following the “standard of care” NCCN guidelines. Not every patient will do well with the one-size-fits-all “cook book” therapies. One big reason for high cancer care costs and poor patient outcomes is over-utilization of cancer treatments, particularly on patients who have sub-optimal functional status, are close to end-of-life, or already suffer from severe side effects. Therefore, treatment decisions, risk/benefit assessment, and doctor-patient communication become critically important here. The whole person approach, which is very well described in the book Healing and Cancer, should be incorporated into the entire cancer care journey, considering all the biopsychosocial, spiritual, financial, and environmental factors when making important and costly cancer decisions.⁴Jonas WB. Healing and Cancer: A Guide to Whole Person Care. Simon & Schuster. 2023; Jonas WB. Whole-Person Cancer Care: A Transformative Vision for Oncology. The ASCO Post. October 25, 2024. Viewed November 11, 2024.
• Set realistic expectations for the patients, especially in stage 4 cases. Discuss hospice and palliative care early on if that is appropriate. Emphasize the importance of quality of life and patients’ goals and values. There is a lot of research published on prognostic factors that help clinicians estimate survival; these are easily accessible on Pubmed.gov ›.
• Plan early. Depending on the specific location and healthcare facility, it may take weeks to get approval and schedule certain diagnostic tests. Therefore, it’s a good idea to plan ahead and order tests early on, even a few months ahead if you believe that patients will need those tests done. That will give enough time for all the paperwork to go through the system. Don’t wait until the last minute and order scans as stat or urgent, as that would put too much stress on the managed care system. Likewise, when you think a patient may need certain treatments soon, even in the next month or so, try to get authorization now and have it ready. This will again avoid the last-minute rush and stress.
• Prepare patients well for treatment. A common complaint (from both patients and providers) is that it takes too long to initiate cancer treatments due to delays in the insurance process. I suggest you take advantage of this “waiting time” and put the concept of pre-habilitation into good use. Research has shown that if patients just take two to three weeks to improve their lifestyle, they will have better outcomes later when they start cancer treatments. You can give patients specific instructions on how to get their bodies “tuned up” while waiting. The Preparing for Cancer Treatment › page on CancerChoices has a lot of resources on this topic. In fact, if it is not an absolutely urgent type of chemotherapy (which is true most of the time in community oncology practice), I personally would prefer to wait two to three weeks before starting any treatment. This will give adequate time to prepare for treatment mentally, emotionally, physically, and spiritually.
• Always think in terms of prevention. Prevent cancer from occurring in high-risk patients, prevent treatment complications, prevent relapse after initial cancer treatments, and prevent pain and suffering at all times. This mindset will improve quality of patient care and reduce costs in the long run.
• Encourage self-care. Managed care organizations may not cover integrative therapies such as massage or acupuncture. Given the already high cost burden on patients (financial toxicity) and time commitment (time toxicity), I would suggest teaching patients self-care methods instead, which are cheaper, faster, and may be just as effective. Instead of acupuncture, use TENS units (electrical stimulation of acupuncture points) which patients can do themselves. They can also do acupressure massage or heating pad or infrared light therapy by themselves or with a family member. Many integrative modalities can also be learned online for free such as tai chi/qigong ›, yoga ›, and breathing techniques ›. The Anticancer Lifestyle Program › offers resources for self-care, and the evidence on how it improves cancer outcomes and quality of life. 
• And lastly, it helps to see healthcare from a systems or holistic perspective. When we do our best to save costs for managed care organizations, they are able to in turn keep the costs down for the tens of thousands of members in their medical group and health plans. In some way, oncologists are not just helping the cancer patients in front of us; we are indirectly saving money for all the other patients who don’t have cancer by keeping their insurance premiums low and affordable. Many of those patients cannot afford more expensive health insurance instead of Medicare Advantage or other low-cost HMO plans. A survey shows that almost a quarter of seniors over 65 years of age have less than $500 in their bank account for healthcare spending.⁵Grunebaum, D. One in Four Seniors Lack $500 for Medical Bills: Survey. Medicare Guide. September 10, 2024. Viewed November 11, 2024. From this perspective, helping insurance plans save costs is related to societal responsibility as a physician. It also demonstrates the concept of holistic health, from person to family to society.

UCLA Center for East-West Medicine › provides online resources for healthcare professionals on integrative medicine. It recently launched a 12 hour CME course on integrative pain management for healthcare providers ›. This is a good resource for those who are interested in a whole person approach to manage pain in people with cancer.