Achieving Higher Quality, Lower Cost Through Oncology Medical Homes

Although still evolving, oncology medical homes have demonstrated the ability to improve patient care, outcomes, and satisfaction while saving money, agreed speakers at a practice management session at the 2015 American Society of Clinical Oncology annual meeting.

An oncology medical home infrastructure affords the most opportunity to sustain contracted bundled payments that involve risk sharing and shared savings, as anticipated with implementation of alternative payment models, said Roy D. Page, DO, PhD, Director of the Center for Cancer and Blood Disorders in Fort Worth, TX. His center is 1 of 10 oncology practices that are involved in a Commission on Cancer accreditation pilot project.

“The oncology medical home concept has now been shown to be a viable foundation to carry out quality-driven, cost-effective comprehensive management of cancer patients,” said Dr Page. “Much of the value gained from the oncology medical home infrastructure comes through refinement of a lot of the day-to-day practice processes that we already do in practice. They just need to be streamlined and refined and made more effective. If you can do that, you can get superior outcomes.”

Oncology Medical Home Domains

The oncology medical home, encompassed by the broader term patient-centered medical home (PCMH), is a physician-led, team-based healthcare delivery model. The design and implementation lead to comprehensive and continuous medical care to patients, while maximizing outcomes.

The overarching objectives of the oncology medical home are to improve access to healthcare, increase patient satisfaction, improve medical outcomes, and achieve efficient delivery of care, while reducing costs. The oncology medical home comprises 5 domains—patient engagement, expanded access, evidence-based medicine, comprehensive team-based care, and quality improvement.

Each domain encompasses several key functions or characteristics, including dedicated triage nurses and a centralized phone system, expanded operating hours, use of navigators and nurse educators, coordination of emergency and hospital management, development and adherence to treatment pathways, existence of patient portals and communication systems, clinical trial support, psychosocial distress evaluation, and a survivorship clinic.

Oncology practices already have in place at least some of the components of an oncology medical home, said John D. Sprandio, MD, Chief Physician at Consultants in Medical Oncology and Hematology, Delaware County Memorial Hospital, Drexel Hill, PA. The transition involves reorganization, establishing information flow, and putting in place the necessary technology support to achieve continuous improvement in care.

Quality Improvement

In 2010, Dr Sprandio’s practice became the first in the nation to receive accreditation by the National Commission on Quality Assurance as a PCMH with an oncology medical home model. The practice has continued to undergo evolution since its inception, Dr Sprandio said.

The process began several years before receipt of the accreditation. The initial steps involved effecting changes to remove barriers to accountable care.

“We streamlined our processes, we standardized our roles and activities, we took away clinically irrelevant activities from our doctors, we fixed accountability to points of control, and we added data systems to track it all,” said Dr Sprandio. “By 2008 or 2009, we realized that we were really improving care coordination, we were keeping people out of the emergency department, and we had reductions in hospitalizations.”

A review of selected data for the practice showed that almost 83% of nurse triage phone calls in 2014 led to at-home symptom management. Only 2% of calls resulted in referral to the emergency department and fewer than 4% necessitated a same-day office visit. Since 2004, the rate of emergency department evaluations per patient receiving chemotherapy annually declined by 80%, and hospital admissions per patient receiving chemotherapy by 50%.

Hospitalizations within 60 days of chemotherapy treatment were 33% lower for commercially insured patients and 61% lower for patients with Medicare Advantage coverage compared with the general population. Rates of hospitalization within 30 days of chemotherapy and use of chemotherapy in the last 30 days of life were below those of other providers. The rate of hospice care during the last 60 days of life also exceeded benchmark values, according to Dr Sprandio.

The improvements were achieved against a background of increased productivity and decreased overhead. The ratio of support staff to physicians decreased from 8.3 in 2007 to 5.6 in 2013, the last year with complete data. Documentation, coding, and coordination all improved, as did physician efficiency and productivity, and patient quality of life.

Cost Controls

The 2 key drivers of the total cost of oncology care are chemotherapy and emergency department visits, especially visits that lead to inpatient admissions. Because medical oncologists have little control over the cost of chemotherapy, emergency department visits became the target for quality improvement in the COME HOME project supported by the Centers for Medicare & Medicaid Services, said Barbara L. McAneny, MD, CEO, New Mexico Oncology Consultants, Albuquerque, which comprises several oncology practices.

National data have shown that approximately 66% of emergency department visits by patients with cancer lead to hospital admission. In the COME HOME project, the rate has ranged between 32% and 53% of visits. In general, medical homes have been shown to reduce inpatient admissions by 15% to 50%, said Dr McAneny. During the first year of the COME HOME project, inpatient admissions declined by almost 10%.

An analysis of 1223 same-day visits of the COME HOME program showed that 20% of the patients would have gone to the emergency department if the office visit had not occurred, and 62% of those patients would have ended up in the hospital.

The cost of a same-day visit averaged $108 compared with $1034 for an evaluation in the emergency department and $9878 per inpatient admission. The numbers suggested that effective triage in the COME HOME project saved approximately $1.6 million a month.

“My unabashed goal is for community practice to continue to thrive, because we are the low-cost, high-quality alternative, and I don’t think the country can afford to move everyone into a hospital-based system where the same service costs one and a half to three times as much,” said Dr McAneny.

Moving forward, oncology practices can remain viable only with successful management of the financial risks associated with alternative payment methods, said Dr Page. Those risks can be lessened by incorporating oncology medical home processes. But oncology practices cannot effect change on their own.

“Without appropriate payer support, further attrition of community-based practices can be anticipated, resulting in escalating costs and decline in value,” he said. “Payers and policymakers need to understand that for providers to implement substantive practice management changes that provide higher quality at lower costs under a system other than fee for service, it is mandatory that the financial value of uncompensated comprehensive services provided through an oncology medical home be recognized in order to be sustainable and scalable.”

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