Value-Based Oncology Care Delivery Falls Short of Addressing Patients' Psychosocial Needs

ELLEN MILLER-SONET, CHIEF STRATEGY AND POLICY OFFICER, CANCERCARE
Friday, January 04, 2019
The ongoing dialogue regarding healthcare payment reform that attempts to incentivize high-value care by linking reimbursement to quality rather than quantity has largely ignored the ultimate consumer/buyer—the patient. Yet, in the minds of clinicians, policy makers, and the public at large, patient-centric care and shared decision-making are fundamental mandates in health care delivery. 

Part of the solution for reconciling these seemingly disparate tensions may well be to consider psychosocial care as an integral part of patient-centered, high-value care. Notably, psychosocial care has been shown to improve patient outcomes and survival, offset medical costs, and reduce unnecessary emergency room use. 

In our recent study, my colleagues and I demonstrate the centrality of psychosocial care to value, based on data from CancerCare’s landmark Patient Access and Engagement Report, 2016.1 The findings reflect the experiences, perceptions, and attitudes of more than 3000 people in the US diagnosed with cancer, and highlight significant gaps in the delivery of psychosocial care from diagnosis through survivorship. 

In an effort to address the implications of patients’ dissatisfaction, we mapped key areas of unmet needs onto the domains of value in cancer care outlined by the National Academy of Medicine in 2013. Through this lens, we have identified service needs where improvement efforts have the potential to enhance the overall value of care for patients.

Most value-based care approaches underrepresent the long- and short-term interests of patients, for whom value includes but extends far beyond dollar costs.

Value frameworks, such as those from ICER and NCCN, attempt to help payers and providers identify treatments that deliver the highest quality care at the lowest cost based upon limited clinical trial data, in which a treatment’s efficacy is viewed in light of its toxicity and cost. This narrow perspective is prompting providers, patients and patient advocates to call for more patient-centric frameworks that facilitate patient-provider shared decision-making.

To be more patient-centered, value frameworks should take into account patients’ compelling psychosocial concerns, such as out-of-pocket , convenience, time and travel burden, impact on family and loved ones, symptom burden, and quality of life.

The CancerCare study indicated that poorly managed symptoms, unmet information needs, and financial hardship were the most commonly cited problems among this sample population. Many survey respondents felt they were not well prepared to cope with symptoms, side effects, and financial hardship that accompanied cancer treatment.  Patients did not have enough information on many aspects of care, but the most severe informational deficits were in their knowledge of insurance coverage and access to psychosocial supports and services.

Respondents were most concerned with getting the best possible care and with the impact that cancer would have on their family and their finances. Certain problems disproportionately affected patients from racial and ethnic minority groups. African American and Hispanic respondents experienced more communication problems with their providers and more commonly felt their providers lacked respect for their cultural, religious and personal values.
                
There is longstanding evidence that psychosocial interventions improve emotional adjustment, reduce distress, and enhance quality of life in people affected by cancer.
Psychosocial care, including psycho-education and counseling, can also improve the economic value of care by offsetting medical costs through increased treatment adherence, self-management, and reduced unnecessary hospital visits.  As such, psychosocial care is considered by many to be an essential adjuvant treatment in cancer care.  

Emerging value-based delivery and payment designs, where value distinctions rest largely on narrowly defined clinical effectiveness, toxicity and cost of specific treatments are sorely deficient and defy the national mandate for patient centric health care. Addressing patients’ psychosocial needs, particularly those identified in this study, are critical to resolving the challenges of delivering value-based oncology care. 
 
Reference
  1. Doherty M, Miller-Sonet E, Gardner D, Epstein I. J Psychosoc Oncol. 2018;19:1-16. doi: 10.1080/07347332.2018.150485.
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