While many oncology practices search for insurers to support the oncology medical home model, a regional payer in Grand Rapids is sponsoring a medical home pilot with five oncology practices in Michigan.
Now in its second year, Priority Health's pilot replaces the buy-and-bill payment system, which ties oncologists' income to the drugs they prescribe, with a pay strategy that ties reimbursement to management of their patients' health, reducing their need for emergency and inpatient care.
The initiative is important because it shows how oncologists can participate in America's move from fee-for-service medicine to value-based care. In this massive shift, public and private payers want to pay physicians more if they provide high-quality, low-cost care—and can prove it. That means, though, that physicians who continue in the fee-for-service system will be left behind financially.
Although some practices have reinvented themselves in the medical home model (OT, 4/25/2012), most are unable to do so on their own, said Kurt Neumann, MD, Medical Director for Quality Initiatives at Ion Solutions, who consulted with Priority Health and PRM, a Michigan consulting group, to devise the pilot. “Payers are going to have to step up and say, 'We will help pay for the process changes for care transformation.'”
Practice leaders at Cancer & Hematology Centers of Western Michigan (CHCWM), a 15-physician practice based in Grand Rapids, believe the medical home model is financially sustainable, said Wendy Koopman, MSN, RN, FNP, AOCNP, Senior Director of Clinical Operations there.
“Whether in the long run this was a good business decision, we will see, but making more uniform toxicity management decisions, patient education, and advance directives enhances the quality of care for our patients,” said Koopman, a nurse practitioner. “You only benefit them in the end.”
One Practice's Experience
CHCWM created an internal medical home implementation team to work directly with Priority Health on the medical home program (see box below). Like other medical home initiatives around the country, the Priority Health pilot involves care management protocols and standardized treatment regimens.
The practice and Priority Health worked together to identify the conditions that should be managed by the practice, but CHCWM created its own evidence-based protocols for each symptom and new processes to standardize care (see “Payment Reforms” box on next page).
After an oncologist sets the plan of care, each patient meets with a nurse educator to learn about what to expect and how to self-manage the side effects. A key message is that the patient should call the practice first when problems arise, rather than head to the emergency department.
“That initial education really focuses on what you need to call for,” Koopman said. “You don't need to call if your temperature is 99, but you do need to call if it's 100.5. You don't need to call if you've had diarrhea once; you do need to call if you've had x many diarrhea episodes over this amount of time.”
The practice re-engineering also involved standardizing internal processes.
“When we looked at nursing documentation, we found that everyone knows what to do for diarrhea, but this nurse might recommend this over-the-counter product this many times, and another nurse might recommend another over-the-counter this many times a day,” Koopman said. “This gives all four of our clinics and our entire organization a common platform for giving advice.”
The practice developed templates in its electronic health record system to coach nurses as they handle patient calls. The template prompts the nurse to ask specific questions about the symptoms, advise patients according to the answers, and record the disposition of the call. For example, he said, “Did you ask the patient to come in today? Did you send them to the ER? Did you ask them to come in tomorrow? Did you tell them to manage it at home? This allows us to collect data on how we are advising patients to manage their side effects.”
Meanwhile, the practice committed to evidence-based regimens for all malignancies and to standardized treatment approaches for small-cell and non-small-cell lung cancer, breast cancer, and colon cancer. For each disease, a small group of physicians was assigned to develop a treatment regimen that all members of the practice would follow.
Order forms were created that specify the doses, lab tests, staging, and other information to standardize the treatment.
Focus on Advance Care Planning
Priority Health's oncology medical home pilot builds on the work of other oncology medical home initiatives around the country, but it may be leading in one domain: advance care planning.
John Fox, MD, Priority Health's Vice President of Medical Affairs, explained that advance care planning is directly connected to the “Triple Aim” (ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx)—a set of values advanced by the Institute for Healthcare Improvement—that informs the insurers' policies.
The Triple Aim has three parts:
* Improving the patient experience, including the quality of care and patient satisfaction;
* Improving the health of populations (for example, all cancer patients insured by Priority Health); and
* Reducing the per capita cost of health care.
While advance care planning was associated with “death panels” during the 2008 Presidential campaign, Fox said a focus on the Triple Aim recasts advance care planning as good patient care.
A facilitated discussion about a patient's goals of care and their end-of-life preferences improves patient satisfaction with their care, responding to the first Aim. That discussion may prompt patients to request early palliative care, which is associated with improvements in quality of life and longer survival (Temel et al: NEJM 2010;363:733-742).
That discussion may also prompt some patients to reject aggressive treatment that does not help patients with their goals. “And how do we reduce per capita cost, the third leg of the Triple Aim?,” Fox asked. “If 10 percent or even five percent of patients say, 'Knowing all the options, that treatment is not going to get me what I want.' We can reduce costs without having to deny care. It's the patient's choice.”
Advance care planning discussions will become routine only if a standardized process and payment policy is in place, he said. Priority Health pays any provider—oncologist, social worker, psychologist, or nurse—who has a facilitated discussion with patients around their goals of care and advance care planning.
“There's a huge gap between what we say we want to do and what we actually do, and that gap results from poor execution,” Fox said. “It's important to have a process and to make sure you can measure that you're doing what you say you want to do.”
Within 60 Days
The oncology medical home practices commit to initiating an advance care planning conversation within 60 days of a patient's first chemotherapy appointment and before any changes in therapy if disease progresses.
A more common approach nationally, though, Neumann said, is to initiate conversations only with patients who have metastatic disease, an approach that may not be the best policy, he said: “By requiring the conversations for all patients, [the caregiver] is not saying to a patient, 'We think you have incurable disease and therefore we are having this discussion.' We think it is much better to say that all adults should have a discussion with whoever their primary care physician is. And with this model, the oncologist becomes the primary care physician for these patients.”
Oncologists in the medical home pilot also agree to place advance directives in a patient's medical record and share the directives with hospitals and other caregivers.
How It Works in Practice
At CHCWM, any new chemotherapy patient has a “meet-and-greet” with a social worker on the same day he or she receives chemotherapy teaching from a nurse educator. The social worker gives the patient a resource book, asks the patient whether an advance directive is already on file, and invites the patient to schedule an advance care planning meeting.
The practice also has an advanced-stage program for patients initially diagnosed with metastatic disease or whose disease has progressed. Those patients are asked to review their advance directives and schedule a visit with the practice's clinical psychologist to discuss their goals, how treatment will affect their goals, and the level of support they need to achieve their goals.
“We really look at whether the way we are treating the patient is working towards not only their physical goals, but also their emotional and family goals,” Koopman said.
While social workers are primarily responsible for getting advance directives updated and the psychologist typically conducts the discussions, oncologists are tasked with introducing the need for the planning discussion.
“The physician doesn't have to sit down and have the hour-long talk about advance directives and the patient's goals related to therapy, but does need to start the conversation with 'This is a change in your disease status; there are many things that come along with it; we want to support you along the way; and I have individuals on my team to help support you through these particular transitions,'” she said.
During the last seven months of 2012, the practice invited 94 patients and their families to schedule an ACP discussion and 53—nearly 60 percent—agreed to do so (see box above).
“We didn't know what to expect, because we had never systematically asked people whether or not they wanted to engage in this conversation,” Fox said. “The most compelling lesson learned out of this to date is when you offer these conversations early on and as part of the standard of care, most people are grateful. No one has been offended. We let our patients know we ask these questions to everyone and just tell everyone that knowing your goals of care, your preferences and priorities will help us take better care of you.”
Of the 41 who declined to have the discussion, 30 cited an existing advance directive as the reason.
That finding shows that that the medical community must emphasize the importance of the conversation, not just the document. When patients say they do not need the discussion because they already have an advance directive, caregivers can use it as a conversation starter. “Caregivers need to say ‘That's terrific. Would you mind if we reviewed that with you because it's important for our team to understand what your wishes are so that we can make sure we support you with the type of care that you want?’”
Three Components of Priority Health's Oncology Medical Home
* Plan pays acquisition cost for drugs
* Difference between fee schedule and invoice is paid as a care management fee for patients on chemotherapy independent of cancer type or mode of administration
* Annual $1,500 per physician per year infrastructure development fee
* Shared savings for reductions in emergency department visits and hospitalizations
* Shared savings for reduced imaging costs (future)
* Incentive payment for quality metrics (future)
* Adherence to preferred regimens, including imaging and monitoring
* Advance care planning
* Survivorship program (future)
* Standardized care management programs
Source: Priority Health
Monthly care management fee for patients receiving active chemotherapy pays for:
* Development and use of protocols to reduce nausea and vomiting; dehydration; constipation and diarrhea; fever and febrile neutropenia; depression and fatigue
* After-hours services
* Care plan oversight
* Medication therapy management
* Patient education
* Team conferences
* Telephone services
* Financial services
* Care coordination
Separate fees are paid for:
* Board-certified genetic counseling
* Advance care planning
* Psychological counseling
* E&M codes
* Infusion fees
* Lab and imaging payments
Source: Priority Health
Priority Health's Advanced Care Planning (ACP) Pilot (May-December 2012).
* ACP was offered to 94 patients.
* 53 accepted, 38 completed the discussion, 33 subsequently completed a written advance directive.
* 23 completed a satisfaction survey; overall high satisfaction was reported.
* 31 of the 41 patients (75%) who declined an ACP discussion cited already having an advance direction on file as the reason.