A Game-Changer for Cancer Rehabilitation

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.

References:
1. Michael D. Stubblefield, MD is a nationally and internationally recognized leader in the field of cancer rehabilitation. Dr. Stubblefield is the senior editor of Cancer Rehabilitation: Principles and Practice, the only comprehensive textbook in the field. 
2. National Coalition for Cancer Survivorship, canceradvocacy.org, March 26, 2020, Dr. Stubblefield webinar: Cancer Survivorship as a Model of Survivorship Care. https://youtu.be/95vDE0AhHvQ
3. Pergolotti, M., Alfano, C., Cernich, A., Yabroff, K., Manning, P., de Moor, J., . . Mohile, S. (2019, May). A health services research agenda to fully integrate cancer rehabilitation into oncology care. Cancer, p. 1.
4. Jalali, A., Martin, C., Nelson, R., Vanneman, M., Martin, B., Cooney, K., . . . O’Neil, B. (2020, February). Provider practice competition and adoption of Medicare’s Oncology Care Model. Medical Care, 58(2), 154-160.
5. Kline, R., Brown, M., Buescher, N., Cox, J., Horenkamp, E., Hoverman, R., . . . Strawbridge, L. (2019). The Centers for Medicare & Medicaid Services’ Oncology Care Model halfway through: Perspectives from diverse participants. Journal of the National Cancer Institute, 111(8), 764-771.
6. Alfano, C., Leach, C., Smith, T., Miller, K., Alcaraz, K., Cannady, R., . . . Brawley, O. (2019, January/February). Equitably improving outcomes for cancer survivors and supporting caregivers: A blueprint for care delivery, research, education, and policy. CA Cancer Journal for Clinicians, 69(1), 35-49.
7. Howe, N. 2020.
8. Alfano, C., & Pergolotti, M. (2018). Next-generation cancer rehabilitation: A giant step forward for patient care. Rehabilitation Nursing, 43(4), 186-194.
9. Oncology Care First Model: Informal request for information. https://innovation.cms.gov/files/x/ocf-informalrfi.pdf
10. Young, G., Schleicher, S., Dickson, N., and Lyss, A. (Feb 2020). Editorial: Insights from the Oncology First proposal: Where we’ve been and where we’re going in value-based care. JCO Clinical Oncology, American Society of Clinical Oncology. https://ascopubs-org.ezproxy1.lib.asu.edu/doi/full/10.1200/JOP.20.00015
11. Healthcare Innovation: Oncology Care First model draws criticism from stakeholders https://www.hcinnovationgroup.com/policy-value-based-care/alternative-payment-models/article/21120847/oncology-care-first-model-draws-criticism-from-stakeholders

Nancy Litterman Howe

Nancy Litterman Howe, M.S., C.E.S. is a cancer survivor and a 4th-year PhD student at Arizona State University, Edson College of Nursing and Health Innovation. As a 2020-2021 National Coalition of Cancer Survivorship (NCCS) Elevate Ambassador, Howe advocates for providing cancer rehabilitation services to people from the point of cancer diagnosis, through treatment, and for the balance of life. Howe lives in Phoenix, AZ. Email address: NancyLHowe@gmail.com

One thought on “A Game-Changer for Cancer Rehabilitation

  1. You make an excellent point that sometimes the greatest innovations come from a person seeing a problem in a different light. Technology is great, but it is only as innovative and useful as the people who understand how to apply and manipulate it. I work at a facility using an EMR that is programmed to find indicators of sepsis, which then triggers an alert to the nurse to take a closer look. This is great in acute care, but things are more complex and more subtle in the outpatient setting.

    I really appreciate the focus on rehabilitation for cancer patients. After a cancer diagnosis, people are living a new normal. In my opinion, there is lack of recovery support and guidance across the whole spectrum of survivors. You found an interesting solution to identify people in need of recovery support, and it saves $27,000 per patient. This is great news, especially since a single cancer prescription can cost more than $10,000 per year (Rimer, 2018).

    Reference
    Rimer, B. (2018). The imperative of addressing cancer drug costs and value. Retrieved from National Cancer Institute: https://www.cancer.gov/news-events/cancer-currents-blog/2018/presidents-cancer-panel-drug-prices

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