Thoughts on IOM’s ‘Delivering High-Quality Cancer Care’ Report

The Institute of Medicine (IOM) makes a number of recommendations on how to improve cancer care in their 2013 report.  I have listed them all here.  For some of these recommendations, I have comments below.

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. 

  • Is improving communication with patients a good idea?  Certainly.  However, should Medicare and other payers pay more for better communication?  It is not entirely clear how good communication would be evaluated.  Further, documenting that you communicated with a patient clearly is not the same as actually clearly communicating with the patient. 

Federal and state legislative and regulatory bodies should eliminate reimbursement and scope-of-practice barriers to team-based care. 

  • In essence, this recommendations aims to reduce regulations that prohibit nurse practitioners, physician assistants and other non-physician clinicians from performing many functions.  Although certification to ensure high quality is generally a good idea, licensing requirements that restrict supply often merely drive up costs with limited quality improvements.

 Congress should amend patent law to provide patent extensions of up to six months for companies that conduct clinical trials of new cancer treatments in older adults or patients with multiple comorbidities.

  • This is a very interesting idea.  It comes from previous efforts to use market exclusivity to promote public health priorities.  “For example, the pediatric patent exclusivity provisions 6 provide manufacturers with an additional 6 months of patent protection for conducting clinical trials of their products in children. The law prevents generic versions of a drug from being marketed during those 6 months.”  I think this makes sense.  However, will it actually spur innovation?  If pharmaceutical companies show that their drugs are effective in a general population, is it worth the risk to perform a second trial where the effectiveness on older individuals (or those with multiple comoribidities) could be less effective?  In fact, the 6 month period of additional exclusivity may not be sufficient to induce pharmaceutical companies to test their products on this market.

Prioritize,  fund,  and  direct  the  development  of  meaningful  quality  measures  for cancer care with a focus on outcome measures and with performance targets for use in publicly reporting the performance of institutions, practices, and individual clinicians.

  • In general, I am supportive of quality metrics.  In places where cancer care is well-established, quality metrics may be useful.  For many cancer types, however, the standard of care is constantly evolving and new treatments and drugs are produced with regularity.  Thus, by the time quality metrics are approved by the appropriate institutions (e.g., AHRQ, NQF), they may already be obsolete.

Academic institutions and professional societies should develop interprofessional education programs to train the workforce in team-based cancer care and promote coordination with primary/geriatrics and specialist care teams.

  • Team-based care is all the rage.  I do believe that collaboration and interdisciplinary work can be beneficiary in many cases, but it is not a magic bullet.  Team-based care require more individuals to participate in the care and is thus more expensive.  Further, in many cases, a single individual may be the one with the most knowledge.
  • Additionally, there are benefits from coordination with the primary/geriatics teams, but also drawbacks.  The IOM report states that many of the advances in cancer care came due to specialization—not interdisciplinary work environments.   Specifically, they state that “Mortality rates for select complex cancer operations have declined by redirecting certain patients to high-volume cancer centers.”  Thus, a blend between integrating generalists and relying on trained specialist is necessary.


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