For most of us, becoming a patient is like being transported to a foreign country without knowing the language and with only spotty cell phone reception. The trip is especially trying for cancer patients because the disease is often deadly serious and treatments bewilderingly complex and spoken about in a vocabulary that only specialists have mastered.
Now a number of cancer centers are using patient navigators to help cancer patients get through a phase in their life that is confusing, full of dread, and, these days, a frightening drain on their finances. The navigators lend emotional support, help with the practical problems of coordinating appointments and transportation, and sleuth around for financial assistance programs, among other things. While some are nurses with clinical training, others are “lay” navigators, who receive training but don’t have health care degrees.
And payers will like this: Preliminary research suggests that these lay patient navigators could substantially lower the cost of cancer care, according to findings from the University of Alabama at Birmingham (UAB) Comprehensive Cancer Center.
Funded by a $15 million Health Care Innovations Challenge Grant from CMS, the UAB center created a program to recruit and train about 40 lay navigators. They served about 30% of the Medicare patients at 12 different sites in the Southeast. Their responsibilities included one-on-one phone and in-person support, and they taught patients about their treatments and how to recognize important symptoms. They also helped providers have discussions with patients about end-of-life care. The training included 24 hours of face-to-face and online lessons and several hours more of skill building and practice. The annual salaries vary but are about $40,000.
The preliminary (and as yet, unpublished) data include claims information from 30,589 Medicare patients who received cancer care from the UAB network over two years. The Alabama researchers announced that they had seen significant drops in health care utilization after the program was implemented, including a 12% decrease in ED visits, an 18% decrease in hospitalizations, and a 14% decrease in ICU admissions. Overall costs fell dramatically from $15,091 to $8,269 per patient per quarter—a saving of $6,822 per patient per quarter, which on an annual basis would be $27,288.
“The impact was even greater than we anticipated,” says Edward Partridge, MD, director of the UAB Comprehensive Cancer Center and principal investigator of the study. ED visits, hospitalizations, and ICU admissions make up about a quarter of the total cost of cancer care, he notes. People with cancer who go to an ED have a 70% to 80% chance of being admitted because their care is too complicated for most ED physicians. And Warren Smedley, a UAB colleague of Partridge’s, noted at a National Comprehensive Cancer Network (NCCN) meeting this fall that Medicare data show that those trips to the ED lead to episodes of care that cost, on average, $19,000.
Navigator costs might ultimately be covered by payment models such as CMS’s oncology program, says Edward Partridge, MD, director of the UAB Comprehensive Cancer Center.
One way that navigators help patients avoid the emergency room is to contact them early in the day to head off potential problems. For example, if someone is vomiting, then perhaps a middle-of-the-night trip to the ED can be avoided when a navigator arranges for a same-day clinic visit so the patient can get fluids intravenously to offset the fluid loss from vomiting.
While the navigators get much of the credit, other changes contributed to the cost savings, according to Terri Salter, administrative director of the UAB Health System Cancer Community Network. Monitoring and regular reporting of performance metrics increased awareness and identified areas for process changes that improved the system and patient care overall, she notes.
Navigation for cancer patients was pioneered by Harold P. Freeman, MD, a surgical oncologist who sought to eliminate barriers to timely cancer care for underserved minority populations in Harlem. Data from his program and others showed that patient navigation can improve cancer survival in minority groups. These successes gave rise to other community-based patient navigator efforts, as well as programs supported by the American Cancer Society and the National Cancer Institute (NCI).
Yet the research hasn’t been entirely positive. An NCI-funded study published last year involving 10,521 patients with abnormal screening results for breast, cervical, colorectal, or prostate cancer found that patient navigators actually increased the cost of care by about $275 per patient and only modestly improved the chances of achieving a definitive diagnosis (although not an earlier diagnosis, which generally translates to lower overall costs). More than 70% of the study participants were minorities, and most either didn’t have insurance or were insured though a government program of some kind. But this study was limited to the initial diagnosis phase of cancer care, whereas the UAB study began at diagnosis and continued through treatment, being a survivor, and end-of-life care.
Studying navigation is challenging, in part because the patient navigator is a relatively new position without defined standards, says Mandi Pratt-Chapman, director of the GW Cancer Institute at George Washington University. “It’s hard to talk about the effectiveness, let alone the cost-effectiveness, of an intervention that’s so highly variable,” she says.
But that’s changing. In October, Pratt-Chapman chaired the inaugural patient navigation meeting of the Academy of Oncology Nurse and Patient Navigators. The organization created national core competencies for lay and nurse navigators in 2014 and plans to roll out a certification process in 2016. Key requirements include navigators understanding their role on the clinical team and when to refer patients to clinical experts.
“As private payers see the results from the CMS innovation study at [the University of Alabama at Birmingham], I think they’ll start paying attention, particularly as we move toward value-based financing,” says Mandi Pratt-Chapman, director of the GW Cancer Institute at George Washington University.
Starting this year, the American College of Surgeon’s Commission on Cancer (CoC) now requires accredited cancer programs to have a navigation process that addresses health care disparities and barriers to patient care. The resources to address these barriers can be onsite navigators or referrals to community-based or national organizations.
Navigation may be especially vital in a specialized field like oncology, where care tends to be fragmented and insurance coverage hard to figure out, Pratt-Chapman points out. People with cancer often see several different types of oncologists (medical, surgical, radiation), nurses, and social workers. They may get care at different institutions. This can mean countless hours on the computer, deciphering websites, and on the phone with payment specialists at hospitals and insurance companies, figuring out bills.
Currently, most patient navigators are paid through grant or philanthropic funding. After funding for its study ends at the end of this year, UAB will begin covering the navigator’s salaries, because they’ve seen the value they offer, Partridge says. Ultimately, he thinks navigator costs will be covered by payment models, such as the CMS oncology program that will pay practices an additional $160 per month for cancer patients receiving chemotherapy as soon as the treatment starts. In return for the upfront payment of $960, the practice has to set benchmarks for reductions in ED visits, hospitalizations, and ICU utilization, as well as meeting quality care measures based on American Society of Clinical Oncology and NCCN guidelines.
Partridge figures each UAB navigator could be responsible for as many as 100 patients at a time. Because most cancer patients receive chemotherapy at some point, that translates to a potential CMS payment of $96,000, which would cover the salaries of two navigators, explains Partridge of UAB.
Value-based payment systems will reward institutions for keeping sick people as well as possible and out of the hospital. If institutions can reach that goal by shifting some of that responsibility from more doctors and nurses to navigators, the benefits could extend to patients, caregivers, and providers, as well as the associated institutions. It should also save money because navigators are paid less than doctors and nurses.