The oncology medical home model will gain traction this year with the launch of a new accreditation program from the American College of Surgeons' Commission on Cancer (CoC).
Seven oncology practices participating in the three-year Community Oncology Medical Homes (COME HOME) project and three other practices plan to participate in a CoC pilot, with the goal of obtaining accreditation in early 2015.
A team that includes representatives from the CoC, the Community Oncology Alliance (COA), and the National Comprehensive Cancer Network have developed the standards that practices must meet to obtain accreditation. To earn accreditation, oncology practices must submit patient data that documents the care that is being delivered.
“This gives us legs to start showing what we are doing, and how we are providing quality and value,” said the chair of COA's medical home implementation team, Carol Murtaugh, RN, OCN, practice administrator at Hematology & Oncology Consultants in Omaha, Neb.
The next step: COA and other advocates of community-based cancer care hope to convince the Centers for Medicare & Medicaid Services and private insurers to pay for oncology services in a new way that rewards practices that can prove they are delivering high-value care.
Even without the accreditation program, some private payers are beginning to increase fees to oncologists who can demonstrate they are controlling costs while providing high-quality care, said Robert “Bo” Gamble, COA's Director of Strategic Practice Initiatives. He said he hopes payers will eventually embrace a shared-savings payment system in which oncologists are rewarded in direct proportion to the cost savings they achieve for payers when they reduce emergency department visits, inpatient stays, unnecessary images, and futile treatments.
Murtaugh said that COA thinks this new pay strategy will give high-performing practices the financial support they need to remain independent, and becoming accredited as an oncology medical home will demonstrate to payers that a practice is worth extra money.
“Practices need to become more viable financially,” she said. “We are looking at the movement of treatments into hospital outpatient departments and we know this increases costs. We need to stop that from happening.”
One of the major proving grounds for COA's concept is the three-year COME HOME project funded by the federal government's Center for Medicare & Medicaid Innovation (CMMI).
The pilot is headed by Barbara McAneny, MD, Chief Executive Officer of New Mexico Cancer Center in Albuquerque. Her company, Innovative Oncology Business Solutions Inc. (IOBS), received a $19.8 million award to support seven community oncology practices as they transition to the oncology medical home model, which emphasizes patient education, team-based care, inpatient care coordination, and enhanced access that gives patients round-the-clock access to the care team.
The project is designed to test whether this model of care delivers on the promise of improving the timeliness and appropriateness of care, reduces unnecessary tests, and decreases avoidable emergency room visits and inpatient stays.
In addition to New Mexico Cancer Center, the other practices in the test are:
* Northwest Georgia Oncology Centers, Marietta;
* The Center for Cancer & Blood Disorders, Fort Worth, Texas;
* Space Coast Cancer Center, Titusville, Fla.;
* Maine Center for Cancer Medicine, Scarborough;
* Dayton Physicians Network, Ohio; and
* Austin Cancer Centers, Texas.
In the grant application, McAneny estimated that the conversion to the medical home model would reduce the total cost of cancer care by at least $33 million over three years.
Last summer, each of the practices adopted “triage pathways”—a set of automated protocols to provide active disease management to aggressively manage nausea, fatigue, and 20 other symptoms in a way that reduces emergency department visits and hospital admissions.
The seven practices have also adopted clinical pathways for seven cancers—pancreatic, breast, lung, colon, lymphoma, thyroid, and melanoma—and to track their adherence electronically.
One of the project requirements was that, by the time the federal award ends in mid-2015, the seven practices must have achieved or be working towards a medical home certification or accreditation.
What Accreditation Means
CoC's accreditation approach supports COA's goals for the oncology medical home model, Gamble said. “They're pushing automation for measurement, they are pushing quality, they are pushing value. All the things that we've been promoting, they are promoting also.”
In addition to the COME HOME practices, three other oncology practices—Hematology-Oncology Associates of Central New York, (Syracuse); Oncology Hematology Associates; (Springfield, Mo.); and Oncology Hematology Care (Cincinnati)—that are also adopting the medical home model will seek accreditation from the CoC program within the next year.
As explained by Laura Stevens, IOBS Program Director, the accreditation criteria are the following:
* Robust use of a certified electronic health record system;
* Use of COA's patient satisfaction survey (see box on next page).
* Evidence that all practice staff understand the oncology medical home concepts and can demonstrate willingness to change policies and procedures accordingly;
* Willingness to share patient-level data to compare patient outcomes with data from other practices; and
* Achievements within several domains, such as the practice of evidence-based medicine or team-based care. Practices may be allowed to choose among several possible achievements. For example, clinical trial enrollment is one measure in the evidence-based medicine domain. Practices that offer clinical trials will be asked to show enrollment logs, while practices that do not may be asked to show policies and procedures for referring eligible patients to clinical trials outside of the practice.
Patient Data Key
COA has also convened a new information technology advisory team to advance the patient-data component of its oncology medical home initiative. The task is to help define the processes and file structure that will allow patient data from a practice's EHR system to be extracted and electronically delivered to a registry.
“Every time a cancer patient comes through the door we will collect certain data points relevant to our quality and value measures,” Gamble said. Those data points—tumor stage, date of treatment, date that survivorship plan was given and so forth—will allow oncology practices to document their performance and allow payers to determine the value of care they deliver (see box).
“This will give us something very concrete that a payer can use to reward certain behaviors,” he said. “Hopefully this is one of the things that will set this model apart.”
Patient Satisfaction Survey
Some payers are already using a practice's scores on COA's patient satisfaction survey to justify higher pay rates, he noted. In the time since the survey—available to any oncology practice at no cost—was introduced early last year, more than 17,000 responses have been collected from patients treated at 2,400 sites of care. Based on the Consumer Assessment of Healthcare Providers and Systems surveys, which are standard in the health care industry, COA's survey allows oncology practices to compare their patient satisfaction scores with those from other practices.
“First and foremost, I want to know how my patients perceive their care here,” Murtaugh said. “But this allows me to benchmark my results against the other practices in my region and nationally so I know how I stand up compared with the other practices.”
Hematology-Oncology Associates of Central New York, which has 17 physicians and 260 employees delivering care in five locations, piloted the survey in 2012 before its official release. Marsha Devita, a nurse practitioner at the practice, says the responses can be analyzed to show how individual caregivers are perceived by their patients.
“The beauty of this survey is the reporting capability,” she said. “In addition to the ability to compare scores to other practices within a region, physicians are able to compare their individual scores within their practice.”
This allows physicians to understand patient perceptions and identify areas where they can learn from each other to improve patient satisfaction. It also helps practice managers understand areas where process improvement may be needed.
Devita's practice uses the survey results as a quality improvement tool. For example, the results of the practice's September 2012 survey showed that only about 88 percent of patients reported that they usually or always were given the results of blood tests, x-rays, and other tests. That reflects the fact that, while abnormal results are always communicated to the patient, normal test and imaging results often were not a priority, she noted. To improve patient satisfaction, the practice added a quality checklist to make sure test results, including normal results, are communicated to patients and introduced a secure patient portal where laboratory results can be viewed online.
“This survey gives you the data you need to improve. And it really makes you examine not only your process, but also what you think your patients want.”
Community Oncology Alliance Medical Home Measures
Patient Care Measures
* Percentage of cancer patients who received a treatment plan prior to the administration of chemotherapy
* Percentage of cancer patients with documented clinical or pathologic staging prior to initiation of first course of treatment
* Percentage of chemotherapy treatments that have adhered to National Comprehensive Cancer Network guidelines or pathways
* Antiemetic drugs given appropriately with highly emetogenic chemotherapy treatments
* Percentage of cancer patients undergoing treatment with a chemotherapy regimen with a 20% or more risk of developing neutropenia and who also received G-CSF/white cell growth factor
* Appropriate use of advanced imaging for early-stage beast cancer patients
* Appropriate use of advanced imaging for early-stage prostate cancer patients
* Presence of patient performance status prior to treatment
* Number of emergency department visits per chemotherapy patient per year
* Number of hospital admissions per chemotherapy patient per year
* Percentage of cancer patients who received a survivorship plan within X days after the completion of chemotherapy
* Percentage of chemotherapy patients who received psychosocial screening and measurable interventions as a result of the psychosocial screening
* Survival rates of Stage I through IV breast cancer patients
* Survival rates of Stage I through IV colorectal cancer patients
* Survival rates of Stage I through IV non small cell lung cancer patients
End of Life
* Percentage of patients who have Stage IV disease that have documented end-of-life care discussions
* Average number of days under hospice care at time of death.
* Percentage of patient deaths in which the patient died in an acute-care setting
* A measurement of chemotherapy given near end of life
* Patient satisfaction reporting and scoring
Source: Community Oncology Alliance
Sample Questions from COA Patient Satisfaction Survey