Chapter 13: Aimed Toward an Interest in Survival; Survivorship Care and the Affordable Care Act

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Chapter 13: Aimed Toward an Interest in Survival; Survivorship Care and the Affordable Care Act

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Dr. Rodriguez begins this segment by sketching how the Affordable Care Act has an impact on care for survivors. She focuses on the assumption payers make that it’s most cost effective to transition patients to their primary care physician after treatment, as oncologists are expensive. She says that is premature for patient who have had aggressive tumors or treatments. Dr. Rodriguez notes that she spoke at ASCO about MD Anderson model of survivor care. She communicated that the four domains MD Anderson uses to structure a care plan is relevant at all stages of cancer care. Dr. Rodriguez then explains that her interest in survivorship was a natural extension of her work with lymphoma patients, as lymphoma was one of the first malignancies that could be cured. She understood early the four domains of Surveillance, Prevention, Late Effects Monitoring, and Psychosocial Health.

Identifier

RodriguezA_02_20150306_C13

Publication Date

3-6-2015

City

Houston, Texas

Topics Covered

Overview; Fiscal Realities in Healthcare; The Healthcare Industry; Discovery and Success; Patients; Patients, Treatment, Survivors

Transcript

Alma Rodriguez, MD:

Well, I know—so I said that I wanted to talk about the Affordable Health Care Act.

Tacey A. Rosolowski, PhD:

Yeah.

Alma Rodriguez, MD:

OK. So there’s a movement nationally now that says, well, oncologists are very expensive, and they order too many tests for surveillance. So let’s transition everybody to primary care after treatment.

Tacey A. Rosolowski, PhD:

Oh, OK, right.

Alma Rodriguez, MD:

And that may be appropriate in some, for some diseases, for some types of malignancies. According to our providers and according to our—what I think we’re learning is that that would be premature for patients who have had very aggressive treatment, or who have had very aggressive tumors. And so, if that kind of concept of how care will be delivered in the future for cancer survivors takes hold, I think we will see a lot of patients who, regrettably, will not do well. I think there is merit to having oncologic care still continue for the period of time at which, or during which, the survivor may be at risk for recurrence of the same disease simply because they already have the relationship with the oncologist if early detection of relapse happens, perhaps a more reasonable—more reasonable options of treatment. Perhaps a what we call a first-line salvage treatment strategy would be workable and feasible, versus patients showing up with very late metastatic recurrence. So pros and cons for both strategies. Obviously on the con side of transitioning the patients, psychologically, maybe, it’s an earlier separation from their identity from the prior cancer. I mean, there could be that psychological benefit. From the healthcare account’s perspective, perhaps the primary care providers are going to do less tests. Maybe, I don’t know. To me, the solution is simply to say the oncologists, you’re accountable for the number of tests you do. (laughs) Justify why you’re doing the tests, rather than saying, you know, don’t see the patients. Anyway—

Tacey A. Rosolowski, PhD:

So, I assume that the, you know, frustration about this is that the Affordable Care Act hasn’t been in place long enough to actually accumulate the data—

Alma Rodriguez, MD:

Correct.

Tacey A. Rosolowski, PhD:

—to provide evidence about that.

Alma Rodriguez, MD:

That’s correct.

Tacey A. Rosolowski, PhD:

So is this office, or other groups or initiatives within MD Anderson positioned to collect this information? Keep track of it?

Alma Rodriguez, MD:

Not yet. Because, quite frankly, I think that there’s a great deal of consternation and there’s huge variability as to how people are interpreting this whole process of transition. In fact, I was invited to speak at the American Society of Clinical Oncology this year about our model of care, and to share with other organizations how we had been doing it. We fully acknowledge that, you know, obviously we are quite unique; we have a huge number of resources. We are very blessed to have all of the number of resources we have. But nonetheless, I think that the model of the domains of health that are relevant to healthcare of the providers—of the survivors, rather—is relevant no matter where the survivor is taken care of. People need to pay attention to cancer prevention. They need to pay attention to the psychosocial health of the patient. They need to pay attention to the late effects that are going to happen. And if you don’t know how to do this, then go learn. And whoever it is who’s going to be providing the care, whether it’s an internist or a family practitioner, or even the oncology practice itself, perhaps, may hire on an additional staff member, and they’ll say, OK, now this is the survivor, so your charge—whoever it is that’s doing the care, however you built the model in your own practice, whether it’s a small practice or a large practice, whatever it is, those four domains of health have to be taken care of. It’s just like saying, if you’re monitoring diabetics, guess what? You have to monitor their fasting glucose or hemoglobin A1C. You have to send them to the ophthalmologist and the podiatrist. You know? It’s the same issue. There are certain aspects of health that have to be paid attention to. And you have to understand which are most important, based on the disease and the type of treatment the patient received. Which is why there is resistance among the internists or the primary care providers, because they said, we don’t know about chemotherapy or radiation. You do. You, the oncologists, do. You are the ones who really should be doing this. And from our perspective, you know, we’re happy to take care of the survivors. It’s just that the pressure is mounting that we not take care of the survivors. And there are pragmatic reasons for that, one, of course, being you’re more costly.

Tacey A. Rosolowski, PhD:

Right.

Alma Rodriguez, MD:

But the other being that there will be fewer of us in the future, it’s predicted that the number of, the ratio of oncologists to the number of patients with cancer diagnoses is going to dramatically shift, and there will be much fewer of us.

Tacey A. Rosolowski, PhD:

Right. I mean, not only are there fewer doctors, but there are increasing numbers of survivors as—

Alma Rodriguez, MD:

Correct.

Tacey A. Rosolowski, PhD:

—treatments become more and more effective.

Alma Rodriguez, MD:

Exactly. Exactly. Exactly.

Tacey A. Rosolowski, PhD:

Right. Huh. Well, I did interview Lewis Foxhall, and he spoke a lot about the community, the education programs for community Physicians, and kind of even attempts to integrate education about oncology care in medical school curricula so that Physicians would have that survivorship and cancer treatment on their radar from the very beginning.

Alma Rodriguez, MD:

Correct.

Tacey A. Rosolowski, PhD:

It sounds like that the initial steps to being able to put oncologists in partnership with physicians in the community.

Alma Rodriguez, MD:

Correct.

Tacey A. Rosolowski, PhD:

Yeah. Really interesting issue, a whole new dimension of activity. Was survivorship—how did you personally become interested in survivorship?

Alma Rodriguez, MD:

Well, I take care of lymphoma patients. And lymphomas are a group of diseases that, actually, from the early days of medical oncology, were one of the first categories of malignancies to be cured by chemotherapy. And so over the years, I have had a large population who were long-term survivors. And so I just noted these problems, so I’m familiar with the issues of, you know, prevention, second malignancies. I can’t tell you how many second malignancies I’ve diagnosed or picked up on routine monitoring and visits, surveillance visits for my patients. You know, having survived lymphoma which, by the way, is not one of the most common malignancies, it usually ranks fifth or sixth for both men and women, but far more common are breast cancer, colorectal cancer, lung cancer, thyroid cancer in women. All those are more common in women, and breast cancer being, of course, the most common. Breast, colon, lung if they’re smokers, gynecologic cancers, thyroid cancers—all of those rank above lymphomas in women. So being aware of those as possible occurrences over the lifetime of my patients was important. They’re not risk-free, just because they were treated from lymphoma. And it’s amazing how many patients would tell me, “Well, I had chemotherapy, don’t you think that would have taken care of all those cancers?”

Tacey A. Rosolowski, PhD:

Oh, yeah.

Alma Rodriguez, MD:

And I go, “No. Actually, unfortunately and sadly, it might even exacerbate your risk for getting those cancers, because the chemotherapy itself, of course they’re toxic chemicals. We don’t know how much they might influence a late effect risk of getting other malignancies.”

Tacey A. Rosolowski, PhD:

There’s actually an article today in the New York Times about, there was a study done of patient and provider’s perceptions of—actually, patients’ perceptions of the relative health or relative benefits versus risks of having certain procedures done, and how pretty much across the board, patients had no clue of how much value—

Alma Rodriguez, MD:

Risks.

Tacey A. Rosolowski, PhD:

—of how much value they were getting and what the risks were, you know? And, you know, most of it was an emotional component that they were bringing to the evaluation of that. So cancer’s certainly on that list, too. Not in the article, but clearly that’s at work—

Alma Rodriguez, MD:

In general.

Tacey A. Rosolowski, PhD:

—in these assessments. Well, would you like to continue with your story about administration at this point?

Alma Rodriguez, MD:

How are we doing with time, because I—

Tacey A. Rosolowski, PhD:

We’re doing well.

Alma Rodriguez, MD:

OK. Great.

Tacey A. Rosolowski, PhD:

We’re at 11:30 now. What time do you ideally have to break today?

Alma Rodriguez, MD:

Let me see, I think the meeting I have to go to starts at twelve—

Tacey A. Rosolowski, PhD:

OK.

Alma Rodriguez, MD:

—something. Twelve fifteen, twelve—I know we start with lunch, so it’s probably sometime around 12:00, and then we sit down and really do business.

Tacey A. Rosolowski, PhD:

OK, so what time would you like to break off today?

Alma Rodriguez, MD:

Let’s break off at noon.

Tacey A. Rosolowski, PhD:

At noon? OK. Sounds good. So we’ve got about a half hour, that’s great.

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Chapter 13: Aimed Toward an Interest in Survival; Survivorship Care and the Affordable Care Act

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