The rising costs of drugs continue to impede cancer program growth, and new technology remains a boon and a bane, depending on its utility for expanding practice capability or its inflexibility to needs, according to the 2017 Trending Now in Cancer Care Survey from the Association of Community Cancer Centers, based in Rockville, Maryland.
The rising costs of drugs continue to impede cancer program growth, and new technology remains a boon and a bane, depending on its utility for expanding practice capability or its inflexibility to needs, according to the 2017 Trending Now in Cancer Care Survey from the Association of Community Cancer Centers (ACCC), based in Rockville, Maryland.
The survey, which featured responses from over 293 program administrators and providers from 209 cancer institutions, was mainly representative of hospitals and academic medical centers, which collectively formed 89% of the surveyed group. Freestanding and independent cancer centers made up just 9% of the total.
Electronic health records (EHRs) continue to be a source of innovation and frustration within oncology practices. Many are struggling with the management of multiple systems (1 in 4 use 4 or more EHR platforms), and these do not always facilitate the communication of data to outside practices. The survey results showed that 51% of respondents reported their EHR systems have interoperability capabilities and 31% said they do not.
EHR systems are still very limited in the type of data that can be transmitted to providers outside cancer programs. Eighteen percent of respondents said they could send provider notes to outside practices; 18%, medication lists; 16%, lab results; 16%, pathology results; 16%, imaging results; 7%, survivorship care plans; and 7%, none of the aforementioned.
The ability to transmit survivorship plans is becoming increasingly important as the number of cancer survivors grows and patients change providers during their lifetimes, making it necessary to ensure continuity of care. However, the survey said that half of respondents find it “very challenging” to meet the American College of Surgeons Commission on Cancer (CoC) Standard 3.3 for issuance of a survivorship care plan to patients at the conclusion of treatment. In addition, 1 in 5 said they find it “very challenging” to meet CoC Standard 1.9 for clinical research accrual, which also is required for accreditation.
Despite the challenges, 80% said accreditation standards and quality reporting programs help them to drive internal quality-improvement efforts, 40% said they use such standards to market their cancer program to referring providers, and 31% use the standards to attract “self-directed” patients.
One thing many agreed with was that EHR systems have increased physician and staff workloads (80%). The survey said half of respondents reported a slight decrease in patient time with providers because of EHRs, and 16% found that clinician time with patients “significantly” decreased following EHR adoption.
Of those institutions surveyed that pursued professional partnerships, 75% affiliated with an existing hospital or health system and 36% forged ties with a private oncology practice. Those joining national oncology groups formed just 4% of the total. Half said a desire to maintain or grow market share was behind these affiliations, whereas 25% said they wanted to increase alignment with hospitals and physicians.
Among difficulties cited in growing practices, the costs of drugs and new treatment modalities was indicated by 68% of respondents; physician alignment around services and program goals, 47%; changes in healthcare coverage, 46%; cuts to fee-for-service reimbursement, 44%; shifting reimbursement from fee-for-service to value-based care, 43%; and marketplace competition, 35%. Nineteen percent of respondents said that marketplace competition had significantly increased.
At the same time, cancer programs are having difficulty recruiting employees. More than half of respondents (66%) said they had full-time equivalent (FTE) vacancies for oncology nurses, just under half (47%) had vacancies for medical oncologists, and 1 in 3 had open positions for advanced practitioners. One in 4 reported FTE nurse navigator and registrar vacancies.
Advanced practitioners were defined mainly as nurse practitioners (81%), followed by physician assistants (41%) and clinical nurse specialists (21%). Twelve percent said they do not use advanced practitioners. Among those who do, the top 3 tasks assigned to these healthcare workers are symptom management, follow-up patient visits in the outpatient clinic, and survivorship visits.
Nurses are heavily engaged in managing patients on oral therapies (63%), with physicians sharing that task (49%) and advanced practitioners (43%) also involved. Pharmacists are doing a portion of this type of work too, according to 41% of respondents.
In the infusion centers, nursing staff are carrying highly variable loads. Nurses might each be assigned 7 to 9 patients per day (46%), 10 to 12 patients, (30%); or 4 to 6 patients, (24%). And at any given time, nurse navigators may have as few as 0 to 25 patients (13%) or as many as 200 or more (8%) under their management.
Staff training for oncology nurses is also variable. In 14% of responding institutions, nurses with at least 1 year of nononcology experience receive 4 to 6 weeks of orientation, 23% said their nurses receive 8 to 10 weeks, and 32% have more than 10 weeks.
Use of oral chemotherapy continues to rise significantly, according to 34% of respondents, whereas 49% reported just a slight increase. Most (96%) said they are prescribing immunotherapeutic agents, but they were not universally comfortable with managing the immune-related adverse events. Thirty-three percent said they were “very comfortable” with this task versus 32% who reported they were “very uncomfortable” with this management.
Although the agent armamentarium has grown increasingly more complex and more homework is required of providers to understand these drugs, only 27% of survey respondents said their oncologists participate in a molecular tumor board. The biggest cited barrier to molecular testing comprised concerns about insurance coverage (82%).
Access to care also was addressed by this year’s survey. The ACCC reported that funding for nonreimbursed services was mainly addressed through the operating budget (63%). Smaller proportions of respondents attempt to charge for these services or cover them through their organizational charitable foundation, philanthropy, or grants.
The survey said 84% partner with community organizations to reach underserved populations, and 84% use translators or translation software to ensure patients can participate in shared decision making.
Preauthorization requirements continue to increase, too. Fifty-one percent of respondents said this rise has been significant, while 31% said it has been slight.
Amid growing emphasis from CMS on management for lower costs and better outcomes, 34% said they are either developing or planning to add symptom management clinics in the next year. A slightly smaller proportion are working on phone triage programs (32%), while others are developing high-risk clinics (31%) and survivorship clinics (34%).
Telehealth is being used in new and diverse ways. One in 3 programs said they plan on using this for genetic counseling and survivorship visits in the next 2 years; 1 in 4 said they plan on using telehealth for symptom management, symptom monitoring, and oral chemotherapy adherence and support in the next 2 years; and 1 in 5 said they would use it for nutrition counseling, psychosocial counseling, medication management, and second opinions in the next 2 years.
Highlights from the 2017 Trending Now in Cancer Care Survey. Association of Community Cancer Centers website. www.accc-cancer.org/surveys/pdf/Trendsin- Cancer-Programs-2017.PDF. Accessed January 25, 2018.