IoM Reports on Challenges of Cancer Care in the U.S.: Urges Greater Emphasis on Informed Decisions in Advanced Cancer Cases
October 18, 2013 08:50 AM
The National Academy of Sciences’ Institute of Medicine (IoM) has completed a new study that identifies a crisis in cancer care in the United States stemming from a growing demand for care, a shrinking oncology workforce, rising costs of cancer care, and the complexity of the disease and its treatment. The report, “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis,” offers several recommendations for addressing these challenges and improving cancer care, including by strengthening clinicians’ core competencies, shifting to team-based models of care, and communicating more effectively with patients.
In the early days of hospice coverage under Medicare, most individuals electing care were diagnosed with cancer. While that has changed significantly over the last 30 years, patients with cancer diagnoses still make up approximately 30 percent of the beneficiary population. The percentage of hospice users with cancer is likely a higher percentage than this, however, due to the widespread practice by hospices of including only a single diagnosis on hospice claims. Over the last 15 months, the Centers for Medicare & Medicaid Services (CMS) has directed, in keeping with ICD-9-CM coding guidelines, that hospices provide the principal and all additional diagnoses related to the terminal condition on claims being submitted for payment.
A relevant part of the IoM report (Chapter 3: Patient-Centered Communication and Shared Decision Making) addresses the need for greater engagement of patients in making “informed medical decisions that are consistent with their needs, values, and preferences”; this section references hospice with some frequency. IoM recommends that the National Cancer Institute, CMS and other stakeholders improve the development and dissemination of this critical information, using decision aids where possible. The study news release notes that, “Patients with advanced cancer face specific communication and decision-making needs, and cancer care teams need to discuss their options, such as revisiting and implementing advance care plans. However, these difficult conversations do not occur as often as they should; recent studies found that 65 percent to 80 percent of cancer patients with poor prognoses incorrectly believed their treatment could result in a cure.” The chapter offers a recommended list of Questions for patients with Cancer to Ask Their Clinicians (Box 3-1), examples of web-based information, resources and tools for patients, and a number of other tools that may help to improve the level of patient and family engagement in the care decision-making process; it also encourages timely referral to hospice for end-of-life care.
Following are the recommendations for Chapter 3 that are included in the report:
Recommendation 1: Engaged Patients
Goal: The cancer care team should provide patients and their families with understandable information on cancer prognosis, treatment benefits and harms, palliative care, psychosocial support, and estimates of the total and out-of-pocket costs of cancer care.
To accomplish this:
The National Cancer Institute, the Centers for Medicare & Medicaid Services, the Patient Centered Outcomes Research Institute, as well as patient advocacy organizations, professional organizations, and other public and private stakeholders should improve the development of this information and decision aids and make them available through print, electronic, and social media.
Professional educational programs for members of the cancer care team should provide comprehensive and formal training in communication.
The cancer care team should communicate and personalize this information for their patients at key decision points along the continuum of cancer care, using decision aids when available.
The cancer care team should collaborate with their patients to develop a care plan that reflects their patients’ needs, values, and preferences, and considers palliative care needs and psychosocial support across the cancer care continuum.
The Centers for Medicare & Medicaid Services and other payers should design, implement, and evaluate innovative payment models that incentivize the cancer care team to discuss this information with their patients and document their discussions in each patient’s care plan.
Recommendation 2: Engaged Patients
Goal:In the setting of advanced cancer, the cancer care team should provide patients with end-of-life care consistent with their needs, values, and preferences.
To accomplish this:
Professional educational programs for members of the cancer care team should provide comprehensive and formal training in end-of-life communication.
The cancer care team should revisit and implement their patients’ advance care plans.
The cancer care team should place a primary emphasis on providing cancer patients with palliative care, psychosocial support, and timely referral to hospice care for end-of-life care.
CMS and other payers should design, implement, and evaluate innovative payment models that incentivize the cancer care team to counsel their patients about advance care planning and timely referral to hospice care for end-of-life care.