A pilot study of 184 cancer patients has found that oncology practices that use cancer care pathways, proactive nurse-initiated support calls throughout a patient's course of treatment, and end-of-life planning can significantly reduce the need for emergency department and inpatient care.
The patients, all newly diagnosed with breast, lung, and colon cancers, were treated by Texas Oncology in its pilot program with Aetna. The results, reported at ASCO's Quality Care Symposium, showed that in the first 12 months of treatment, patients had almost 40 percent fewer emergency room visits, 16.5 percent fewer inpatient admissions, and about 36 percent fewer inpatient days compared with other newly diagnosed cancer patients in Texas.
Aetna's preliminary estimate is that the one-year cost for those patients was about 10 percent lower than it would have been for identical patients in the year before the pilot. By contrast, the insurer saw the costs of care for other Texas cancer patients rise by an average of 15 percent during that year.
Savings continued in the second year; estimated cumulative savings for the first two years increased to 12 percent.
“Not only did they flatten the trend of rising costs—they actually saved money,” said Ira Klein, MD, Aetna's Medical Director.
Why It's Important
Although Aetna reported on a relatively small number of patients, the results of the pilot add to the growing body of evidence that oncologists can lower the cost of cancer treatment by making changes in the way they care for their patients.
“This worked out tremendously well,” Klein said. “It's really the first study that has been done of a population of this size, with this rigor, that shows this kind of great results.”
In 2010, the U.S. Oncology Network and Aetna reported that, in its study of patients with non-small-cell lung cancer, annual outpatient costs were 35 percent lower for patients treated using U.S. Oncology's Level 1 pathways versus off-pathway—with no difference in patient outcomes (OT, 3/10/10).
More recently, Consultants in Medical Oncology and Hematology, a practice in southeastern Pennsylvania, reported that it cut the rate of hospital admissions per chemotherapy patient by half over a four-year period after converting its practice to a patient-centered medical home model. That practice model involves extensive patient education, telephone support, and same-day access to a physician when patients report side-effects symptoms that threaten to send patients to the emergency department (OT, 4/25/12).
Taken together, these studies—and others that will be reported in the months ahead—are convincing insurers that the seemingly relentless climb in cancer costs can be slowed and perhaps even reversed. That means that all oncologists will feel increasing pressure from payers to improve the way they care for patients and save money by doing so.
When Linda Bosserman, MD, President of Wilshire Oncology Medical Group in southern California, publishes the results of her practice's own pilot study later this year, it will likely add to that pressure: A review of 10 months of data about some 600 cycles of chemotherapy found that fewer than one percent of patients had an ER visit or an inpatient admission.
“No practice should be afraid of this,” she said in an interview. “It puts the practice back in charge of caring for patients. This is the future.”
How They Did It
Aetna's results reflect the experience of patients who started treatment between June 1, 2010, and January 30, 2011. The oncologists participating in the pilot agreed to:
* Comply with the treatment pathways developed by the U.S. Oncology Network.
* Provide oncology nurses to call patients after their first chemotherapy session and throughout the course of treatment to check on their well-being, screen for depression, and coach them to recognize and manage side-effects and symptoms.
* Offer access to end-of-life planning and support.
Klein said that oncologists improved their performance on all three elements of care. A review of patient records for 18 months after they were enrolled in the pilot showed that:
* Physicians' adherence with disease-specific pathways increased from 67 to 75 percent.
* 81 percent of patients received supportive care calls from oncology nurses—“If the patient said, 'You know, I had my second week of chemo, first dose yesterday, and I just feel so wiped out, I'm having a lot of diarrhea and I don't really have any appetite, and I haven't drunk much,' that person would be automatically vectored back to the practice so that they could avoid an ER visit the next day for kidney failure or syncope collapse,” Klein said.
* 83 percent were introduced to the concept of advanced care planning.
The Aetna-Texas Oncology pilot used a shared-savings payment model, meaning that the insurer and oncologists shared the savings that were generated from the improved care. The oncologists' shared savings payout was equal to or more than the money they would have made under the traditional “buy-and-bill” payment method for those patients, Klein noted.
What to Do Now
Any oncologist who wants to move to a new payment model needs to initiate discussions with the practice's major payers. In southern California, Bosserman said the lead-up to Wilshire Oncology's pilot project with Anthem Blue Cross was time-consuming.
“It took me five years to work through all of the medical directors, actuaries, contracting, and leadership,” she said. “I think there's a growing movement that this can work, but health plans are very traditional and they are very siloed.”
Roy A. Beveridge, MD, Chief Medical Officer for McKesson Specialty Health and the U.S. Oncology Network, agrees that the dynamic between insurers and oncologists is evolving; physicians are recognizing that they need to demonstrate high value care and oncologists are open to payment ideas that seem likely to slow the growth of cancer care costs. “I think the world has changed in the last couple of years,” he said. “There used to be much more of an adversarial relationship between oncologists and payers.”
In addition to Texas Oncology's pilot with Aetna and Wilshire Oncology's pilot with Anthem Blue Cross, U.S. Oncology affiliates in Colorado and Florida are experimenting with new types of contracts, and others will be announced later this year. Each practice is trying different payment systems and collecting data to see which elements of a new system work well and which do not.
While most observers think that straight fee-for-service and buy-and-bill contracts are on their way out, Beveridge doubts they will be replaced by a single payment system that is universally adopted.
“What may work in Colorado may not be the thing that's going to work in Virginia or Seattle or Boston,” he said.
In Florida, Advanced Medical Specialties (AMS), which operates 16 cancer treatment facilities in south Florida, is experimenting with a shared-savings contract in conjunction with Florida Blue, the Blue Cross Blue Shield plan in that state, and Baptist Health South Florida, the area's biggest health system. The contract went into effect earlier this year, but the details of the new relationship are still being worked out.
To succeed, AMS and Baptist Health must agree on new care processes—for example, increasing access to same-day appointments so patients do not have to go to the emergency room when they suffer side-effect symptoms from their treatments—and ways of coordinating care. Meanwhile, the insurer must support them by changing some of its own policies and procedures.
“It takes months to exchange the data needed to agree on a contract, and it's going to take longer to get all the care processes in place,” said AMS Chairman Leonard Kalman, MD. “This is clearly a two-, three-, or four-year project, and hopefully everyone has enough respect for each other and everyone will be flexible, because I'm sure we're going to have to tweak the contract.”
Even though it is not yet clear how AMS's contract will work out, Kalman encourages other oncologists to accept that payment reform is coming and to be proactive in creating the new pay system that will work for them.
“Just sitting down with your hospital system and with a payer and working on trying to improve care and make it more cost-effective creates a new environment that is very beneficial,” he said. “If you don't start practicing these things, then payment reform may leave you behind.”
The Value in End-of-Life Planning
As oncologists try to improve the value of the patient care, they run into a huge barrier: The biggest waste of money goes to futile treatment delivered to patients who are near death, but improving end-of-life decision-making is not easy.
“Our society is so geared toward the rare miracle that, even when we tell them we don't think treatment is going to be helpful, [patients] think it could cure them,” said Linda Bosserman, MD, President of Wilshire Oncology Medical Group in Los Angeles. “It's just an unrealistic promotion by universities, academic centers, and private doctors.”
Indeed, when the American Society of Clinical Oncology joined the “Choosing Wisely” campaign earlier this year, it identified “the use of chemotherapy for patients with advanced cancers who are unlikely to benefit” as the top example of a common cancer-care practice that is not supported by scientific evidence.
As ASCO CEO Allen S. Lichter, MD, said in an article he wrote for OT (5/10/12 issue), the oncology community has a responsibility to maximize the value of cancer care: “By ‘value,’ I mean care that is driven by the best available evidence and by patient needs, while minimizing unnecessary and unproven interventions,” he said.
Aetna's pilot with Texas Oncology is among the first to evaluate the use of advanced care planning as a way of improving value—the highest quality care delivered at the lowest cost—in cancer care.
Physicians participating in the program agreed to offer access to end-of-life care planning and support. During the 18 months for which patient records were reviewed, 83 percent of patients were introduced to the concept of advanced care planning, “which is probably four times what happens in the United States on average,” said Aetna Medical Director Ira Klein, MD.
The impact of that increased focus on end-of-life planning is not likely seen in the results Aetna has reported because it studied outcomes for only a 12-month period.
“We think that, over time, these programs will have actually more impressive results, because 12 months is not the usual time course from diagnosis to death,” Klein said. “If you have a program that facilitates discussions between doctors and patients [that influences end-of-life treatment decisions], we are not going to see the maximum savings for two to three years.”
Although a high percent of patients were offered advanced care planning, only 11 percent completed an advanced care plan.
“It's very hard, believe it or not, to get people to do an advanced care plan,” noted Leonard Kalman, MD, Chairman of Advanced Medical Solutions (AMS), a large oncology practice in southern Florida. “It's an uncomfortable subject for everybody.”
Patients who have completed an advanced care planning process typically have earlier referral to hospice and less chemotherapy, fewer emergency department visits, fewer hospital admissions, and fewer intensive care unit admissions in the last 30 days of life.
As part of its new shared-savings arrangement with Baptist Health South Florida, a large health system, and Florida Blue, the state's largest private insurer, AMS is trying to improve end-of-life planning and decision-making. The practice already employs a nurse practitioner who meets with patients to encourage them to complete and sign the Five Wishes document and identify a health care surrogate.
“I need to get a higher percentage of people to the advanced care planning nurse practitioner so I asked the hospital to use their marketing dollars to push this. We'll market it some. I asked Florida Blue to market it—they are a little hesitant,” Kalman said. “I said, 'Florida Blue, give the patient an inducement to do an advanced care plan. Give them a gift certificate to Macy's or Disney World.' They are hesitant to do that.”
Meanwhile, Roy Beveridge, MD, Chief Medical Officer for McKesson Specialty Health and the U.S. Oncology Network, said he finds that insurers have not supported palliative care—an essential component to good end-of-life care—appropriately: “The response by payers to compensate palliative care has been shockingly abysmal, to the point that the economic sustainability of people in palliative care doesn't exist,” he said. “My concern is you can have a great idea, but unless it's embraced and compensated for, then the idea won't move forward.”
PODCAST: Eliminating Futile Treatment
As oncologists try to increase the value of care they deliver, most agree on the biggest opportunity for improving patient care and saving money: the elimination of futile—and often debilitating—treatment for patients who are near death.
Listen on the iPad edition of this issue to Linda Bosserman, MD, President of Wilshire Oncology Medical Group in Los Angeles, discuss the need for better end-of-life planning so that oncologists can improve the value of the care they deliver.
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