Sometimes innovation happens when one person, looking at the same data that everyone else is looking at, sees something stunningly new. This blog describes exactly that: an innovative model of care for cancer rehabilitation that can be implemented through public policy.
Game-Changer: A Model that Makes Money
The innovation model developed by Dr. Michael Stubblefield MD1 uses the EMR (electronic medical record) to integrate cancer rehabilitation into a survivor’s treatment plan from diagnosis through the balance of life2. The game-changer is that his solution makes money for healthcare providers.
Stubblefield’s model solves a constellation of problems in a single stroke. In a nutshell, the intractable problem for cancer rehabilitation has been sustainability. No one could answer the question, “Who foots the bill?” so every proposed medical solution has been dead on arrival. Current 2020 estimates are that nearly 90 percent of the 17 million cancer survivors who could be helped by cancer rehabilitation don’t receive it3. That is the missed opportunity Stubblefield addresses.
Like many innovations, conditions aligned. Standardized access to a patient’s EMR is happening, and Stubblefield’s model depends on EMR technology. Value-based reimbursement structures are being piloted by Medicare & Medicaid through the CMS Oncology Care Model (OCM), 2016 – 2021, a 5-year experimental program that applies specifically to oncology patients receiving chemotherapy. Evidence about the success of this approach is mounting4. Under OCM, providers who deliver high quality care in both quality and satisfaction, and who simultaneously lower costs, will receive a portion of the savings. The incentive is simple: More money spent more wisely results in more profit for providers5.
Key Public Policy: CMS’s Oncology Care Model (2016-2021)
OCM identified three large-expenditure targets: lower unplanned hospitalizations, lower non-essential ER visits, and improved pain control. Cancer rehabilitation achieves all three targets, and it does it very well1.
Evidence indicates that up to 23% of unplanned oncology hospitalizations are due to fatigue, a condition that cancer rehabilitation specializes in solving (usually through tailored physical activity). Women with lymphedema have a higher likelihood of visiting the ER compared with women who don’t, and the costs savings are significant: about $27K per person1. NCCN guidelines on pain management specifically recommend cancer rehabilitation as a pain control strategy1. The economic justification for cancer rehabilitation is contained in these numbers. The first huge hurdle is overcome.
Stakeholder Support Starts with Oncology
But in the real world of today, we remain hamstrung by fee-for-service, and the lack of coverage for all but the most egregious impairments. Certainly there is no money for an exercise program6. Rehabilitation is a low priority, addressed after treatment (if at all), and rehab specialists are faced with overlapping, cumulative impairments. Referrals to cancer rehabilitation depend on oncologists having the time, the knowledge, and the experience to recognize functional impairments that can be ameliorated by cancer rehabilitation. Even more, the oncologist is expected to know what type of referral to make because different rehabilitation reimbursement codes are associated with each rehabilitation specialist8.
Innovations Bring New Problems
There is no denying that problems have yet to be worked out. Relying on value-based reimbursement assumes that the healthcare system will adopt programs that include the advantages of the OCM, and correct the identified problems.
Already, a new model based on OCM successes and failures, Oncology Care First, is being proposed for 2021 amid editorials, commentaries, and blogs written by stakeholders who are debating its pros and cons9, 10,11. It is difficult to project unanticipated outcomes. Cancer rehabilitation will be integrated into cancer treatment when leaders of healthcare systems see evidence that providing rehabilitation services can improve both patient care and their bottom line.