Believing that the patient-centered medical home concept holds great potential for cancer care, the Community Oncology Alliance (COA) is working to develop the model for oncology practices and prove its merits to payers.
About 20 oncologists and practice administrators gathered in Dallas in January to discuss the initiative.
“The idea of the medical home is built around the concept of enhancing the quality of the care to the cancer patient, and the value of the care, not only to the patient, but also to the payer,” said Ted Okon, COA's Executive Director. “If it can be shown how the cost of care is being reduced in a model like this, payers are going to be very receptive.”
Value in cancer care—defined as high quality care delivered at the lowest cost—can be boiled down to two basic concepts: Standardizing processes so that every patient receives the most appropriate care from diagnosis through survivorship; and managing side effects so that patients do not require emergency department (ED) and inpatient care.
COA leaders have approached the Centers for Medicare & Medicaid Innovation about a demonstration project in which Medicare would pay oncology practices that use a patient--centric model of care. COA is also talking with private payers about a demonstration project.
The premise of the medical-home model is that payers would pay physicians for providing the services (see “Oncology-Specific Patient-Centered Medical Home Goals”) that keep patients out of the ED and hospital, thus reducing the payers' total health care costs substantially.
Although the patient-centered medical home concept was developed for primary care, COA leaders are inspired by the experience of Consultants in Medical Oncology and Hematology (CMOH), a nine-physician practice in suburban Philadelphia.
Led by John D. Sprandio, MD, CMOH is the first oncology practice in the nation to be recognized by the National Committee for Quality Assurance (NCQA) as a Level III Medical Home—the highest designation possible (See “Results from Nation's First Oncology Medical Home”).
Started Preparations in 2004
CMOH physicians began transforming their practice in 2004, preparing for the day that oncologists would be paid for the quality of care they provide.
“Medical oncologists should not be paid for services based on which drug they select; payment should be on the level and quality of services they are actually providing,” Dr. Sprandio said. “I saw [buy-and-bill] as a very short-lived business model, I am surprised it lasted as long as it did.”
Community oncology practices provide care to about 80% Americans who have cancer. But as the payment dynamics have changed in recent years, both providers and payers are looking for alternative ways to sustain community-based oncology.
Alice Gosfield, a five-time chair of the NCQA—and Dr. Sprandio's attorney—says that his development of the Oncology Patient-Centered Medical Home (OPCMH) model presents that alternative.
“This is actually a challenge to the payers,” she said. “They have got to put their money where their mouth is.”
CMOH offers many value-based services—support in making and keeping appointments for tests and treatments, same-day access to a physician for evaluation of symptoms, and extensive patient education and telephone support, among others—that increase costs for the practice. It also has the information technology that monitors disease management, physician performance, and patient outcomes.
“It's astonishing to me that payers don't look at this and go, ‘Oh, my God! This is exactly what everybody should be doing,’” she said. “They deserve to be paid more because they get better results, they're more efficient, and they have actual information to prove it.”
Currently, only one private payer—a Medicaid HMO—is paying CMOH for the OPCMH services the practice delivers. Dr. Sprandio says he hopes to negotiate OPMCH-related contracts with two additional payers in the Philadelphia market this year.
“The bottom line is that, unless the insurance industry supports this effort, we either have to discontinue providing the enhanced services or we have to turn our practices over to the hospital systems and universities,” he said.
Working on ‘How-to’ Template
Meanwhile, Dr. Sprandio, in conjunction with COA, is working to create a “how-to” template so that other practices can follow in CMOH's footsteps. He has proposed a blueprint of the “three phases of construction” of an OPCMH to local payers and like-minded practices.
“A lot of people see the benefit of this, but they don't know how to go about doing it,” Mr. Okon said. “So one of our initiatives is to develop the model more fully to show how practices can phase into it and see what it means ultimately in terms of their reimbursement.”
Because the concept is so new, the best way to pay oncologists for providing medical home services is not yet clear. COA is attracted to the model because it creates a way for oncologists to be paid for the supportive services that patients need, legislation dictates, and physicians WWwant to provide—while answering payers' demands that overall costs be reduced.
“This is not willy-nilly just reducing costs, but actually reducing costs while enhancing quality,” Mr. Okon said. “What we're trying to do here is to produce the desired results, and then we can get more creative about how the reimbursement system is applied to it.”
Oncology Patient-Centered Medical Home, Defined
The patient-centered medical home is one of the most important concepts being developed to change the way physicians are paid.
To be recognized by the National Committee for Quality Assurance as a PCMH, a physician practice must demonstrate that it meets nine standards (see box on next page). Practices that meet those standards should, by definition, provide care coordination and communication that lead to high-quality, low-cost care and high patient satisfaction.
As of the end of 2010—just two years after the recognition program was introduced—about 7,700 primary care physicians at more than 1,500 practice sites had been recognized as a PCMH.
The idea is that practices that have earned the PCMH recognition should be able to negotiate better contracts with payers for delivering higher quality, better coordinated care.
The PCMH model was developed with input from the American College of Physicians, American Academy of Family Physicians, American Academy of Pediatrics, and American Osteopathic Association—and is for primary care specifically.
In an email exchange, Peggy Reineking, Director of NCQA's Recognition Programs of NCQA, said the organization recognized a small number of specialty practices, including Consultants in Medical Oncology and Hematology, but does not plan to do so in the future.
“We are not pursuing a strategy to recognize more specialty practices,” she said.
John D. Sprandio, MD, lead physician at CMOH, coined the term “oncology patient-centered medical home” to describe the CMOH practice.
He noted that the NCQA is working directly with the ACP to develop standards that would allow specialty practices to receive a new type of recognition called Patient-Centered Medical Home—Neighbor. NCQA interviewed CMOH representatives about this last summer, he added.
“The concept of an independent entity assessing and recognizing a practice's performance is critical to confirming an enhanced level of service and results worthy of enhanced financial support from payers.”
That said, CMOH did not set out to achieve the NCQA recognition, which was not even in existence when the practice started re-engineering its processes of care in 2004. Rather, the practice started by investing in an electronic health record system and developing additional software that allowed it to capture and analyze data about its performance in an effort to better serve its patients.
All the advancements the practice has made since then rest on health care IT and a culture of continuous process improvement.
“You really have no idea how you are performing as a practice until you start measuring,” Dr. Sprandio said. “Only then can you go back and improve your processes of care and thus your performance.”
Patient-Centered Medical Home Standards
Consultants in Medical Oncology and Hematology Met These 9 Standards to Earn the Highest Level (Level 3) Recognition as a Patient-Centered Medical Home from the National Committee for Quality Assurance in 2010. In Jan. 2011, NCQA Issued an Updated Set of Standards
* Increased patient access and enhanced communication.
* Patient tracking and registry functions, including reminders for preventative screenings.
* Care management and adherence to nationally accepted, evidence-based standards of treatment.
* Patient self-management and support to avoid potential complications of treatment and disease.
* Electronic prescribing and physician ordering.
* Test tracking and monitoring patient compliance.
* Referral tracking.
* Continual performance reporting and improvement.
* Advanced electronic communications including a portal for patients and referring physicians.
Source: Community Oncology 2010;7 (12)
Results from the Nation's First Oncology Medical Home
Since 2004, Consultants in Medical Oncology and Hematology, a four-site practice in suburban Philadelphia, has transformed from a traditional practice to a patient-centered medical home.
Almost every process of care has been reengineered, courtesy of the robust use of electronic health record technology, a staffing plan that creates a patient-centered health care team, and a relentless devotion to monitoring, measuring, and improving outcomes.
The results, published in Community Oncology in December (2010;7: 565-572) include:
* A steady decrease in the number and rate of emergency department referrals for chemotherapy patients. The current practice average is fewer than one ED visits per chemotherapy patient per year.
* Hospital admissions for CMOH patients fell by 16% between 2008 and 2009—and fell another 10% in 2010.
Those statistics can be attributed to standardized care management, a tenet of the patient-centered medical home model, according to John D. Sprandio, MD.
A standardized approach to dehydration prevention education and management results in fewer patients seeking ED and inpatient care for dehydration, while standardized management of outpatient diarrhea has cut the number of admissions for treatment of Clostridium difficile enteritis by more than 50%.
Likewise, standardized prevention of delayed nausea and vomiting due to chemotherapy has dramatically decreased the practice-wide use of oral 5-hydroxytryptamine 3 inhibitors.
What It Means for Patients
The oncology medical home model requires that patients be fully engaged in their care. CMOH has standardized patient education so that patients hear the same advice from physicians during office visits as they hear when they call the nurse triage line.
“We're making them responsible, to become better reporters,” Dr. Sprandio said. “If they wake up at eight o'clock in the morning and think they might have a problem, they should call by 8:15. Calling us late in the day may result in an unnecessary ED evaluation.”
Helping patients avoid the ED is less burdensome on them and their families—while saving money for payers.
The number of unscheduled office visits within 24 hours of a call to the triage line more than doubled in the five years after CMOH started educating patients to be engaged in their care and report symptoms early.
What It Means for Oncologists
Dr. Sprandio noted that one of the goals of CMOH's re-engineering was to minimize irrelevant activities that steal time from the physician's day. While the number of patients treated at the practice grew by 29% over five years, the number of physicians did not change. Indeed, the physicians' total working hours decreased as they became more efficient.
The practice puts a priority on thorough and timely documentation. The physicians use voice-recognition software and a standardized documentation process via customized software.
Furthermore, because of its IT systems, the practice operates in a paperless environment, eliminating the problem of lost charts and misfiled reports.
Making it Work
CMOH is providing improved patient care with a smaller staff than the practice used to have, even though a fourth office location was added in 2006.
“We operate with about eight FTEs [full-time equivalent employees] less than we did in 2002, with the same number of physicians,” Dr. Sprandio said.
The practice's staff members are more productive. Several administrative assistants have been reassigned as patient navigators who are responsible for scheduling all tests and appointments, monitoring to make sure patients follow through, and following up with them if they have not.
Nurses answering the triage line have been trained to use symptom management algorithms to respond to patients' symptoms. Because of this, more than 75% of the clinical calls to the practice's triage line result in patients managing their symptoms at home rather than going to the emergency department or to the office unnecessarily.
Oncology-Specific Patient-Centered Medical Home Goals
Consultants in Medical Oncology and Hematology Developed These Goals to Translate the Patient-Centered Medical Home Tenets to Oncology Care
* Streamline and standardize patient evaluation.
* Coordinate all aspects of cancer-related evaluations and services via patient navigators.
* Promote an interdisciplinary approach to management.
* Constantly collaborate between clinical support and treatment teams.
* Stress patient education, engagement, and compliance.
* Proactively manage patients' symptoms via extended hours, telephone triage services, and physicians on-call.
* Minimize clinically irrelevant physician activity.
* Fix accountability for care delivery at the physician-patient locus.
* Assume ownership of cancer-related needs in a highly personal way.Source: Community Oncology 2010;7 (12)