It's Time to Prove Value and Move the Needle on Quality

Jennie R. Crews, MD, FACP

In March, Jennie R. Crews, MD, FACP, was appointed president of the Association of Community Cancer Centers (ACCC), replacing Steve D’Amato, BSPharm, BCOP, and taking over at a time when oncology practices are under acute pressure to transition from fee-for-service payment to value-based care, a process of abrupt change.

OncLive: Please describe your practice in Washington and Alaska.

Has the value transition reached that area of the United States?

What is it about your background and your interests that makes you the choice for leading the ACCC at this time?

Any particular experiences that enable you to not only empathize with the members, but perhaps propose or lead solution-driven changes?

What are the top challenges facing oncology practices today?

In an interview with OncLive, Crews, who is medical director for cancer services in the PeaceHealth Northwest Network, talked about how her 18 years of diverse activity in the oncology sector would translate into strong leadership for the ACCC and its membership of 20,000. During the question-and-answer session, Crews also discussed the top challenges faced by oncology practices as well as strategies the ACCC is following to help its membership meet and rise above those challenges.Dr Crews: PeaceHealth for Cancer Services has four different cancer programs, the largest is in Bellingham, Washington, and that’s kind of our primary cancer center. It’s the largest of the four. We have four medical oncologists, three radiation oncologists, and a physician’s assistant (in Bellingham). We have a medical oncologist at one of our other sites full-time, and then the other two sites operate as satellites. We go out to Peace Island Medical Center, which is on San Juan Island, and we go to Ketchikan, Alaska. And those two satellite sites are unique in that they can only be reached by air or water.It is starting to. I think the Northwest part of the country has been a little slower than some other regions in seeing some of this transition happen, but we’re beginning to feel that occurring now. There have been a number of practices in the state of Washington that have applied to be part of the oncology care model that The Centers for Medicare & Medicaid Services (CMS) is introducing, which is a foray into the value-based world. So we are on the cusp of entering that, absolutely.I’m, first of all, very honored to be selected to serve as president of this organization. It’s a unique organization in that it really contains membership from various models of providing care. We have academic members, we have community practice members, we have hospitalbased members. And one of the things that I’ve had the privilege of doing is practicing within all of those environments: I’ve been an academic oncologist, I’ve practiced in a private practice multispecialty group, and I’ve also practiced, and currently do so, in a community hospital—based cancer center. So, I feel like I have an understanding of the membership and can represent all of those points of view.In my leadership roles, on the board of ACCC, I’ve been involved in a number of initiatives and have also been able to learn from the organization. One of the great things about the ACCC is that it is truly a learning organization. We like to say we’re not about the “why” or the “what,” we’re about the “how.” We’re focused on implementing practice changes. One of the great things that we do at our fall meeting is share with one another, and there are innovator awards that are given to organizations that are doing interesting and different things. So I’ve been able to really learn from my colleagues within the organization and hear what they’re doing to prepare for the value-based world.We do annual surveys of our membership on top trends in cancer care. One of the challenges is the lack of reimbursement for support services. One thing that’s important is having a team-based approach with services such as social workers, dietitians, and navigators, etc, who are very key to the oncology team in providing care coordination for patients and addressing their holistic needs. But many of these services aren’t supported, and so it’s a huge challenge for our membership to be able to offer all of these things to patients when we’re not reimbursed for those services.

Another challenge has been implementing quality initiatives. One of the major focuses of going into a value-based environment is what is value to the patient and how do you prove that, and what is quality and how do you move the needle? There are a number of helpful organizations and benchmarks, and there are some great quality initiatives, but it often takes time, and money, and other resources to make these happen. And benchmarking sometimes is a challenge, as well—comparing yourself with the standard.

Another challenge has been patient access to affordable care. Oncology centers and practices out there have been challenged by transparency in cost and being able to provide patients accurate estimates of the costs of oncology care. There is also a need for financial advocates for patients who are facing rising co-pays and coinsurance.

What is the ACCC doing to address these challenges?

New technologies and new treatments are also a challenge. Practices struggle on how to implement this new technology and how to incorporate new treatments, how to manage side effects from new therapies.Some of them are being addressed through ongoing initiatives. We have a financial advocacy network that offers online programs for patients. We have kind of a how-to book that people can adapt and use for their personal needs at their cancer centers. We have the Institute for Clinical Immuno-Oncology, an ACCC initiative that is designed to provide education and support for providers, patients, and cancer centers in implementing immuno-oncology, understanding issues surrounding reimbursement, and helping with side-effect management, among other things. One of the initiatives that we’re focusing on this year, which is part of my presidential theme, is patient-centered care; it’s just getting started. We’re going to define patient-centered care and what the program will encompass for the upcoming year.

Part of having patient-centered care is patient empowerment; what that means is providing care that honors a patient’s personal preferences and their values and needs. I think that it really requires an oncology team to do this, and members of that team include traditional people like nurses and physicians, but also financial counselors, navigators, and social workers. But patients need to be a part of that as well, and I think they could have a role in helping cancer programs develop strategies and programs that are meaningful to them. It also involves incorporating patient decision-making tools so that for issues around treatment, patients and doctors can have a conversation regarding what are the goals, what is important to me, what side-effect trade-offs am I willing to live with, and what kind of financial impact will this therapy have on me?

What else is important to your constituency at this time?

Then those decision tools can extend across the cancer continuum to also be of importance in discussing end-of-life issues and patients’ goals. Around reimbursement, I think the challenge for us is that we want to think in new ways about how we’re reimbursed for the care that we give and really be paid for the value that we bring, which is having time to have these conversations with patients and having a team approach to care that supports the patient’s mind, body, and spirit.There’s a lot of excitement around new models of care. We have some members of our organization who have participated in the oncology medical home (OCM) model. We have a number of members who have applied to participate in the OCM project through CMS, and we’re waiting to hear who will be selected for that. They’re all very excited about coming together to support one another, to be able to share best practices.

Also, there’s a lot of concern about the payment changes in the Medicare Part B proposal from CMS. Stakeholders weren’t really approached to be involved in that decision before it was released. Members are wondering how that would work with some of these new models of care that people are piloting.

With so much change in the works, what’s the practice of oncology going to look like in 10 years?

I think that we want to be collaborative with CMS and partner with them as they roll out new initiatives. We want to offer better care and more cost-effective care to our patients, but I think that the way to do that is to proactively partner with stakeholders rather than release a proposal without stakeholder input, because of the downstream consequences of that. I think what we’d like is for CMS to put a hold on rolling out this proposal and have us all come back to the table to talk about how we might be able to achieve objectives in a more mutually agreeable way.I think it’s going to look somewhat different. I think we’re seeing a slowing down of the mergers and acquisitions that were very popular over the past few years. But I think what we’re going to be looking at in the future of oncology is different ways of working with others to provide care. It’s obvious that there’s a shortage of oncologists, and we’re going to need to think about creative ways to deliver care. I think we’re going to see people working to the maximum of their license, and we’re going to be looking at team approaches to care where nursing has a huge involvement, and where mid-level providers—advanced practice clinicians—are used more in oncology settings.

I think we’re also going to partner with people who we haven’t necessarily thought of as being part of the medical team; for example, relying heavily on primary care as we transition patients back to primary care after their treatments are completed. We’re going to be partnering with palliative care more, I think, as the future goes forward. I think that the concept of oncology care to the patient is going to be really one that expands to a greater team and is more collaborative. But I also think that there’s going to be individual and regional variation in different ways of achieving this. So I think there’s still room for people to be creative and very individual.