SGO Calls for Broad Changes in Managing Patient Care

Ronald D. Alvarez, MD

Professor and Vice Chairman, Department of Obstetrics and Gynecology Director, Division of Gynecologic Oncology University of Alabama Birmingham, AL

When it comes to gynecologic cancer care in America, the glass is half full.

That’s the opinion of the Society of Gynecologic Oncology (SGO), which contends in a recent white paper that only half the American patients with gynecologic cancers receive care that adheres to National Comprehensive Cancer Network guidelines.

Moreover, the SGO maintains, studies show that nearly 50% of US women with early-stage ovarian cancers do not undergo the recommended surgical staging procedures. Half of those newly diagnosed with the disease have surgery performed by “less-skilled surgeons in low-volume hospitals,” according to the society, and up to half of women with endometrial cancer are managed by healthcare providers who are less equipped to make decisions about their therapy.

The white paper, entitled “Creating a New Paradigm in Gynecologic Cancer Care: Policy Proposals for Delivery, Quality and Reimbursement,” calls for changes in the medical management of women with gynecologic cancers—beginning with their referral to doctors who specialize in treating those diseases.

The SGO asserts that women with gynecologic cancers frequently receive uncoordinated, fragmented testing and treatment from multiple providers at a variety of sites, often without the involvement of a gynecologic cancer specialist or supportive services such as education, physical therapy, mental health aid, or financial or genetic counseling. That lack of structure often leads to deviation from guidelines, repeat testing, inappropriate treatment, and, ultimately, added costs, the document states.

“We have evidence to the effect that many ovarian cancer patients aren’t getting the standard of care, and that when care is provided by people who are knowledgeable and have training in this area, and who treat a large volume of patients with these diseases, outcomes are better,” said Ronald D. Alvarez, MD, director of the Division of Gynecologic Oncology at the University of Alabama at Birmingham and immediate past president of SGO, in an interview. “We’re trying to lift up the whole bottom part of the medical system to at least meet the minimum standards for how patients with gynecologic cancers should be managed. It’s hard to go forward if we haven’t caught up yet.”

A Model for Improvement

Alvarez said the SGO developed the report to help its 1600 members with practice-based issues and to influence policy makers, particularly those in the federal government, now that the Affordable Care Act is being implemented. “We felt that we needed to develop a roadmap for how we thought cancer care should be delivered, because if we didn’t, somebody else would have done it for us,” he said.The white paper’s central recommendation is the establishment of a model that would funnel each woman with gynecologic cancer to a specific expert care provider, or “medical home.”

Under the strategy, gynecologists, primary-care physicians, and other generalists would be encouraged— when presented with a woman diagnosed with, or suspected to have, a gynecologic cancer— to refer the patient to a physician with multidisciplinary training in such diseases. The idea is as logical as sending heart patients to cardiologists or stroke patients to neurologists, Alvarez said.

The physician receiving the referral, most likely a gynecologic oncologist, would then serve as “team captain” of a pool of practitioners who would participate in the patient’s treatment. Team members could include medical or radiation oncologists; pathologists; diagnostic or interventional radiologists; palliative care physicians; nurse practitioners or physician assistants; oncology nurses; oncology pharmacists or pharmacologists; genetic counselors; social workers; physical therapists; psychologists; and lymphedema specialists, the SGO wrote in the paper.

Funding the System

The SGO is calling for demonstration projects to test the program within several existing care-delivery systems. Funding could come from the Centers for Medicare & Medicaid Services (CMS) and large health insurance companies, Alvarez suggested.The SGO’s team-care strategy could help eliminate waste caused by a system that not only requires extraordinary amounts of paperwork, but rewards doctors for volume and intensity of therapy, leading to overutilization of resources and an inadequate focus on coordination of care or palliation, the SGO wrote.

“The more you do, the more you get compensated,” Alvarez said. “No one asks, ‘What is it that you do, and how valuable is that?’ The alignments in the system have to be that people are paid based on the value they provide, rather than on quantity.”

To make that happen, the healthcare system will have to reimburse doctors differently, Alvarez said.

Gynecologic Cancers: Annual Impact

^aNew cases and deaths are estimates for 2013.

^bCosts are estimates of national expenditures in 2010.

Sources

Cancer topics: types of cancer. National Cancer Institute website. http://www.cancer.gov/cancertopics. Accessed April 29, 2013.

Costs of Cancer Care. Cancer Trends Progress Report — 2011/2012 Update.

National Cancer Institute, NIH, DHHS; Bethesda, MD; August 2012; http://progressreport.cancer.gov/doc_detail.asp?pid=1&did=2011&chid=105&coid=1026&mid=. Updated June 20, 2012. Accessed April 29, 2013.

Under the SGO’s proposed plan, a bundled-pay system would reimburse a team for a woman’s care, with different portions of the payment going to various team members depending on their level of involvement. General gynecologists and primarycare physicians would be financially incentivized for their referrals, and team captains would receive compensation for coordinating a woman’s care.

On the flip side of the coin, Alvarez said, healthcare practitioners would face a loss of revenue for veering from the plan.

“It’s not always about whether they know how to do a procedure—they do—but whether they know the disease’s context and management,” he said. “If somebody takes a patient with carcinomatosis to the operating room but should have known better, is it reasonable to compensate that person for doing a procedure that they didn’t do right and that they’re not skilled at?”

The SGO also suggested the development and testing of three other payment models.

One calls for a bundled-payment approach without a coordinated care team or captain. Under another plan, doctors at each site of service would be paid a flat fee associated with each single diagnostic episode of a woman’s illness, with the level of reimbursement based on the disease’s stage and associated guideline-based treatment strategies. A final plan would pay gynecologic oncologists a monthly sum based on the number of patients they typically treat, and on predicted patient population.

The white paper is available on the SGO website at http://tinyurl.com/bh32rro.