The Community Oncology Alliance (COA) is bringing oncologists, insurance companies, and patients together to develop a new business model for the delivery of cancer care.
Originally developed for primary care, the patient-centered medical home model is an example of the “value-based” delivery models that payers are demanding. Oncology is getting special attention because of the high costs of cancer care and the widespread belief that, through changes in the way care is delivered and paid for, patients can get better care for potentially less cost than insurers are now paying.
Oncology is the first specialty to adapt the medical home concept for its own use. Because payers are moving so aggressively to control costs, COA Executive Director Ted Okon says it is essential that oncologists put forth their own model for delivering cancer care: “This is about taking the lead and not being led,” he said.
Although only a few medical home contracts are currently in effect, the general idea is that oncologists who control cost for a patient's entire episode or care while meeting or exceeding predefined quality targets are rewarded financially for doing so. Under a medical home contract, payers reimburse oncologists for the cost of the drugs they deliver, pay them for the cognitive services they provide to patients, and offer some type of incentive for providing high-value care.
“Clearly, oncologists don't have any control over what drug companies charge for their drugs, nor do we really have much of a choice as to whether we use those drugs if it is the appropriate clinical indication,” said Bruce Gould, MD, Medical Director of Northwest Georgia Oncology Centers (NGOC) in Marietta.
“There are, however, other things that oncologists can control, such as hospital and emergency room utilization, the amount of testing they do, and to a certain extent, how much drug therapy they use on a patient who has metastatic cancer.”
How this can work has already been proven by Consultants in Medical Oncology and Hematology, a nine-physician practice in Drexel Hill, Pennsylvania. That practice went through a six-year transformation before practice leader John D. Sprandio, MD, published results showing that the medical home model can sharply reduce ER and hospital use (see box).
Since then, payers have been beating a path to suburban Philadelphia to find out how the medical home model works.
COA's goal is to bring payers and oncologists together so they share one vision for the future of cancer care delivery, Okon said. “What we are trying to do is create unity and a common platform for the medical home so that providers and payers can come together to advance quality and value in cancer care for patients.”
Getting All Stakeholders on Board
COA's first order of business: figuring out what “value” means in oncology care.
“Value means different things to different stakeholders,” said Gould, who chairs the steering committee for COA's medical home initiative. The committee started its work by soliciting input from three stakeholder groups—patients, payers, and physicians—to learn what each of them considers to be “value.”
To get the patients' perspective, NGOC hired a marketing consultant to interview 20 oncology patients. Then Gould, along with NGOC Executive Director Scott Parker, and Bo Gamble, COA's Director of Strategic Practice Initiatives, interviewed all stakeholders serving on the steering committee, including a patient, patient advocates, payers, physicians, and other clinical staff.
The committee reviewed the information collected to find common values and came up with these five:
* Cancer care that is coordinated with the central focus on the patient and their entire medical condition
* Cancer care that is optimized based on evidence-based medicine to produce quality outcomes
* Cancer care that is accessible and efficient, with treatment provided in the highest quality, lowest cost setting for the patient,
* Cancer care that is delivered in a patient-centric, caring environment that optimizes patient satisfaction.
* Cancer care that is continuously improved by measuring and benchmarking results against other facilities providing care so that best practices “raise the bar” in delivering care.
The Work Ahead
With those priorities in hand, Dr. Gould's 17-member steering committee is working to determine the essential components of an oncology-specific medical home, how a medical home practice can document and report the value of care it is providing, and how oncologists should be paid for operating as a medical home.
“We have a pretty aggressive timeframe to have this worked out, at least on paper, within the next six to nine months,” Gould said.
In broad strokes, the elements of an oncology-specific medical home needed to deliver the value that all stakeholders want have been identified:
* Guidelines—not only for using oncology drugs and supportive care drugs, but also for the appropriate use of imaging, blood work, radiation therapy, and other diagnostic and treatment services.
* Patient satisfaction surveys. Survey findings must be used to identify and correct deficiencies in the practice—and must be reported to payers, which may use them to determine a physician's pay.
* Protocols for reducing emergency department and hospital admissions. Among other things, this may require nurse navigators who call high-risk patients daily to monitor symptoms and intervene early if patients have problems.
* Patient education protocols that teach patients how to be engaged in their care by following medical orders and re-porting problems before an emergency department visit is needed.
* Extended office hours.
* The use of nurse practitioners or physician assistants to expedite admissions, coordinate care and facilitate discharges for patients who must be hospitalized. “If we really try to compress that length-of-stay, it could result in substantial cost savings,” Gould explained.
* Early end-of-life planning discussions.
The steering committee is also charged with identifying the data that practices will use to report the value of the care they are delivering. Gould listed several possible reports: guideline compliance rates, ED and hospitalization rates, hospice length-of-stay, and the average length-of-time between final chemotherapy administration and a patient's death.
“Those types of reports would serve as tools for the payers to see who is providing quality care, and who is not,” Gould said.
The final task of the steering committee is to determine how medical home practices will be paid. Payers want to get away from the current buy-and-bill payment system that ties physician pay to the drugs they prescribe. However, payers will push for “cost-neutral” arrangements in which they pay no more to oncologists than they are currently paying—even though the practices will be expected to provide extended hours and new services.
“Maybe initially it's not going to be [cost-neutral], but hopefully in the long term, the benefit to them will be that the cost curve will be bent, and they will get better value for their health care dollar,” he said.
Preparing to Evolve
While the steering committee is doing its work, Carol Murtaugh, RN, OCN, Administrator for Hematology & Oncology Consultants in Omaha, Nebraska, is chairing the implementation team.
The team of eight practice administrators is evaluating tools, policies, and best-practice procedures that oncology practices can use to operate as a medical home for cancer care. Gamble, who administered a large practice before joining COA, understands why many oncologists and practice executives may be worried about the transition to a medical home model.
“Having been there, I know your plate is full, and you say, ‘No, I don't have time for one more project,’” he says. “We are trying to be very sensitive to that as we look at tools and processes that can help practices—and not add to their cost or add to the administrative burden, but help them get to where they need to be.”
Among other things, the implementation team is evaluating cancer care pathways vendors, patient portals that give patients easy access to their medical records, policy templates, and other tools.
“One in particular that is very important is the patient satisfaction survey,” Murtaugh said. “We are looking at that as a measurement tool and a way for practices to standardize their assessment of patients on a variety of levels.”
As the team identifies items that would be helpful in transitioning to a medical home, it will identify them on a COA-sponsored website.
“We are not taking an exclusive approach, because we want [the website] to be a home for all good things in cancer care—even if there are competitive products,” Gamble said. “If it is a good tool, we want to include it in this menu.”
What to Do Now
Murtaugh said she expects that many leading oncology practices will find that the medical home model is not so different: “A lot of what we are doing [in the medical home model] are things that oncology practices are already doing. While the terms may seem new and the way we are going about this may seem different, this isn't reinventing the wheel.”
Her advice to oncology practice leaders:
* Get informed. COA's implementation team will launch a website later this spring to help oncologists and practice administrators stay apprised of medical home developments and learn about improving and documenting value of the care they deliver.
* Prepare to adopt new ways of doing things. The implementation team will post templates for policies and procedures that should be standard in an oncology-specific medical home.
* Do a practice assessment to identify what changes will be needed to succeed in a medical home contract.
* Be prepared to benchmark your performance against other oncology practices.
Gould encourages oncologists to see the medical home initiative as an opportunity to thrive going forward: “If done properly, it provides a better patient experience, it provides better value for the health care dollar, and it strengthens community oncology. That is the whole goal of our program—to hit on all three of those points.”
Getting Oncologists on Board
At COA's recent annual meeting, enthusiasm for the medical home concept ran high, Okon said. But many oncologists are not yet aware of what a medical home is. When the Association of Community Cancer Centers surveyed its members in February, 32 percent of the 216 respondents said they were unfamiliar with the concept of an oncology medical home or had heard of it only in passing.
On the other hand, 13 percent of respondents said they expect to be operating as a medical home within two years and 18 percent expect to make the transition within five years.
Community Oncology Alliance Medical Home Initiative
A wide range of stakeholders from across the country are working together to develop the oncology medical home as a new business model for cancer care
© 2012 Lippincott Williams & Wilkins, Inc.
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