In this interview, Dr Barbara McAneny discusses how her multidisciplinary oncology practice integrates psychiatry, primary care, and palliative care, emphasizing the importance of practical communication tools, internal collaboration, and leveraging oncology infrastructure to meet broader community needs.

Please state your name, title, and any relevant experience you’d like to share.

Barbara McAneny, MD: I'm Barbara McAneny, MD. I am a medical oncologist and the CEO of New Mexico Oncology Hematology Consultants at New Mexico Cancer Center. I'm the co-chair of ONCare Alliance and a former president of the American Medical Association.

What are some practical first steps for practices looking to integrate psychiatry, primary care, and palliative care into their oncology services?

McAneny: We do this through a pathway-like phenomenon. We recognize, for example in psychiatry, that we are doing a Patient Health Questionnaire-2 (PHQ-2) survey on all of our patients because we know that, as a cancer-focused multidisciplinary practice, there is a huge impact of depression in our patients.

We learned this during the COVID-19 pandemic, but it's always been there. We created an internal pathway so that anyone who scores a 3 or higher on that depression screen is automatically referred to a telepsychiatry company that we have contracted with to then administer an additional survey and determine how much depression is affecting them and then offering them that telepsychiatry solution. We have hardwired it in so that there's the automatic referral for people who screen positive, but we also have it so that any clinician who feels that their patient would benefit from psychiatric support or counseling support is eligible.

We also set it up so that our nurses will include those questions and offer that when we do certain required nursing visits. For example, when we have people who are starting a new chemotherapy regimen, we do a chemo teaching visit. The nurse practitioners who are doing those visits need to offer those questions, and we hardwired it into the note in the electronic medical record (EMR) so that there's that automatic reminder that this is part of what we want them to offer to the patients.

For primary care, it's a little bit different. It seems to me that no one—no state, no practice—has enough primary care doctors around, and patients certainly don't have a primary care doctor that they can get to in a timely manner. They may be assigned one by a health plan, but they've never seen them and can't get in when they need to. We look at that as a co-management process. We have integrated our primary care as co-management.

If we're seeing a patient for breast cancer and they also have diabetes and they haven't checked their hemoglobin A1C for a long time, if they have a primary care physician, we will call them and ask them if they would like to co-manage with us. If they say no or they don't have a primary care physician, we refer them to our internal primary care for the purposes of co-management. What we find is that then helps with survivorship and palliative care.

We do the same thing with palliative care. If any patient wishes to have hospice, then that's pretty easy. We stop therapy and we refer to hospice, but we will also co-manage a lot of the symptoms with our palliative care physician. That is not a hardwired in thing because that's a very individual need. We don't automatically do that.

I don't like the process. I think it's important to make that very patient specific as to when it is appropriate to involve palliative care. We separate out palliative care from hospice. If there are symptoms that a patient is having that I can't control, I call my palliative care team and have them help with that and co-manage the patient with me. That's not end-of-life care, which is hospice. I separate those in the practice.

How do you measure the success or impact of a multidisciplinary approach—both in terms of clinical outcomes and patient satisfaction?

McAneny: Patient satisfaction is the easy part. Patients love it. They get so frustrated when the right hand doesn't know what the left hand is doing. Because we are structured as a multidisciplinary practice, we have medical oncology and radiation oncology, but we also have urology and pulmonary and rheumatology, so we can do internal referrals very easily.

There are a lot of hospitals that say they have coordinated care because everybody's paycheck is signed by the same person. That doesn't do it. Coordination of care is clinicians talking to each other and saying, "Okay, if you'll manage the diabetes, I'll do this part, " or "This is going to mess up their heart. I can't use that approach. What can we do so that I have some options for this patient?" That's physician communication.

Our success for that is harder to measure. We're not really set up to keep long-term statistics on outcomes measures because, as a practice, that is a huge expense that we are not paid to do and can't afford to get the resources for. However, when we survey patients about their satisfaction, they love that. We can see some of our success in certain things, like the way we manage people who need concomitant chemotherapy and radiation therapy, which is a very toxic regimen. We can look at how often people are having to have a break in their radiation because they have so much toxicity they can't keep doing it.

We do watch our hospitalization rate because patients who are needing multidisciplinary care, when they fall through the cracks, they're more likely to end up going to an emergency department or a hospital. We measure all those rates. All the way through the Oncology Care Model (OCM), which made it easy for us to have a comparator because the OCM data from the Centers for Medicare and Medicaid Innovation gave us the statistics to compare ourselves to other participants in that program.

Our hospitalization rate was about two-thirds of what the other practices in that program were. To me, that's a measure of how much impact we have from our multidisciplinary approach.

What tools or strategies have proven most effective in ensuring seamless communication and coordination across such a diverse clinical team?

McAneny: I'm smiling at that because it comes back to everybody who thinks signing the paycheck out in the front means you have integrated care. You don't. It's communication. We make sure that we have secure internal chats that we can do with other clinicians so that if you get a text, you're in with some patient, you don't have to interrupt what you're doing and ask the question, but you can answer it later on in the chat or you can call somebody if it's a longer conversation. We make sure that all of our doctors have each other's cell phone numbers. That has been one of the benefits of electronic medical records. They are mostly constructed, particularly the hospital-based ones, so badly that doctors now talk to each other on their cell phones. When I read a consultation on an inpatient, I know that consultant could maximize their bill, but I have no idea what they think. I have to call them.

We also have an internal tumor board. One of the things that I've just started to do is having the younger physicians in every one of our specialties get together in an informal situation and have people start to talk about the challenges they see in their specialty and what the interaction is between the others. You would think, for example, what do a rheumatologist and radiation oncologist have to talk about? Apparently, there are some new processes where you can give low-dose radiation to osteoarthritis and make people comfortable for a couple years, which is a lot less toxic than taking an NSAID forever and wiping out your stomach.

We'll have a lot of very good collaborations come from that. Having people get to know one another will help us with the governance of the practice and getting people to think in a more multidisciplinary fashion.

Are there any other points about multidisciplinary care that you'd like our audience to take away from this?

McAneny: It's very interesting to me that a lot of the allied health professionals want independent practice, whereas physicians have long realized that they don't actually practice independently. They need a whole team of people around them to be able to do what they do.

The question for physicians is how do we create all of those multidisciplinary collaborations? That is an evolving process. What we're trying to do by making communication easy and simple is what's going to make a huge difference in allowing us to collaborate on top of the formal processes we have, such as having board meetings where everyone sits in the room together and says, "How are we doing?"

The other thing is our basic physical plant structure encourages collaboration. The radiation oncologists are 100 yards down the hall from where I'm sitting right now. If I get a 5-minute gap, I can walk down the hall and say, "Hey, I've got this patient, I think this might help. What do you think? Do you want to see them? I'll get them set up." Those are the kinds of things that really help. Being able to give a lot of curbside second opinions is very valuable.

There are 2 takeaways I want people to think about. There are a lot of things that we can use the resources of an oncology practice for, where we have imaging and infusion, to solve community needs. At New Mexico Cancer Center, we just established an Alzheimer disease program. There was a neurologist who was struggling in his practice and needed some assistance, and we've created an Alzheimer bundle so that anybody who's concerned about early Alzheimer disease or memory loss can get their workup done within a few weeks as opposed to months and be able to take advantage of the fact that there are new drugs that we can infuse in the infusion center at about half the price and in a much more comfortable setting than a hospital system. We can leverage what we have as infrastructure to branch out a bit and be able to solve other problems in the community.

The other thing people need to recognize is that the fee schedule for surgeons is completely messed up. The surgeon's professional fees have been valued so low, and the technical fees—the part the hospital gets—are valued so disproportionately high that, if a surgeon had to live on their professional fees alone, they would probably be paid like primary care doctors. They wouldn't even be able to afford their malpractice insurance.

We need to recognize that if you incorporate a surgeon into the practice, the hospital is going to make a bunch of the money, but you have to look at what you're getting as downstream referrals that keep those patients within the other parts of the practice that are better reimbursed.