While there are many quality-focused oncology practices in North America, they approach quality improvement in different ways—for example, by use of expert-generated guidelines, such as those produced and updated by NCCN and ASCO, or by participation in ASCO's Quality Oncology Practice Initiative (QOPI), in which compliance with quality measures is measured and the results (blinded as to specific practice) returned to participants so they may judge how they compare with others.
The American College of Surgeons also has developed standards of care and, partly because of the technical and regulatory nature of its work, the American Society for Radiation Oncology has long had standards for aspects of the process of care and for equipment function. There are also significant and effective homegrown quality efforts in individual practices or health systems, such as Geisinger, Virginia Mason, and the Permanente Group.
But in my personal experience, which is limited, of course, there is one focus of quality efforts that appears to be unique in its structure, reach, and effectiveness. I believe it could be a model for other practice groups to emulate.
I attended a meeting a few weeks ago of a Michigan organization of medical oncology practices that was an early adopter of the QOPI project, but has taken quality to a new level that I have not seen elsewhere. The catalyst of their success is a partnership with Blue Cross Blue Shield of Michigan (BCBSM).
First, BCBSM offered to cover the costs of data abstraction for those practices that participated in QOPI, a cost normally borne by the practice. This enabled even two- to four-person practices to participate because they would not have been able to afford the expense otherwise. This program dramatically increased the number of participating practices, and Michigan became a poster child for the QOPI program.
After several years of data collection, BCBSM and participating practices recognized that additional resources and expertise were needed to further advance quality improvement efforts. In mid-2009, BCBSM funded the Michigan Oncology Quality Consortium (MOQC), a collaboration of QOPI-participating oncologists, ASCO, and the University of Michigan (UM). UM acts as a coordinating center for QOPI data-entry, quality improvement, and process improvement throughout the state. Though BCBSM has previously sponsored hospital-based quality-improvement collaboration, the MOQC effort is the first office-practice based collaborative funded by BCBSM.
Building on the QOPI Experience
The Consortium proceeded to build on the QOPI experience to address gaps in the quality of cancer care identified by the doctors themselves. They began to target interventions to improve management of cancer pain and the incorporation of primary palliative care into oncology practice in Michigan. MOCQ is a lively organization with strong leadership and an impressive degree of participation and loyalty. The group meets several times a year to discuss progress or the lack of it.
Since BCBSM had laid the groundwork for such activities in cancer and other medical specialties, it would be useful to digress for a moment to explain the background and scope of their programs, which go far beyond oncology.
BCBSM is a large, single-state, not-for-profit Blue Cross Blue Shield plan, which had 4.3 million members in 2010. In 2006, BCBSM developed its Value Partnerships program as a hospital, physician, and payer partnership to improve the quality of medical care. The Physician Group Incentive Program (PGIP) is one component of the program. There are currently more than 40 PGIP initiatives in which nearly 15,000 Michigan primary care physicians and specialists representing 40 physician organizations participate.
PGIP initiatives focus on measurable improvements in structure, process, outcomes, and performance; respect physicians' roles as primary owners of the patient care relationship; provide performance rewards to recognize prepared, proactive teams; and reward participants for improvement and collaboration, not just high performance.
BCBSM provides the funding that supports data registries and analysis; administration and incentives for participation and performance; serves as a catalyst for change by uniting providers to improve care throughout the state; and, depending on the initiative, provides clinical advice and expertise to ensure the success of the initiative.
This is a truly visionary application among health care payers, raising quality and efficiency to the top of the priority list, and not just with formulaic words, but also with action and financial investment.
This support enabled MOCQ to develop a system of quality improvement based on determining the root cause of non-compliance, ranking them by importance and testing new approaches to overcoming that shortfall, using targeted projects for small groups of representative physicians.
In other words, they have moved from measurement to influencing improvement by comparison with tailored interventions. Ultimately, they will install a rapid learning structure for continuous quality improvement. Such a system was described in the Journal of Clinical Oncology (Abernethy AP, Etheredge LM, Ganz PA, et al. Rapid-learning system for cancer care.2010; 28:4268-4274).
Increasing Reimbursement for Care by Oncologists Who Participate in Quality Improvement and Show Progress
BCBSM has pushed the envelope even further by beginning a process of increasing the reimbursement for care by oncologists who participate in quality improvement and show progress in the quality of care.
And the physicians, nurses and office staff have pushed the envelope of their activities further, as well. They have formed the Michigan Breast Oncology Quality Initiative and the Michigan Oncology Clinical Treatment Pathways Program. Detailed analyses are routinely carried out to assess the actual practice patterns and to compare them with accepted standards. This practice is well developed in breast cancer but it is also being examined in other areas. These groups have excellent participation and communication both among and between them.
What is remarkable about these activities is the level of collaboration between many oncology practices large and small, a university cancer program, and a major health care insurer. Even more remarkable is that this group continues to extend its reach in scope and its aspirations for better performance.
The mood at the meeting was exhilarating; a sense of engagement and pride were quite evident. They like doing this because they believe it is the right thing to do. They volunteer their time to make things better organizationally and for their patients.
Although there must be interest in controlling the cost of care, I never heard this discussed substantively by the doctors or by representatives of BCBSM. I believe that they have confidence, as I do, that if you give higher quality of care, the costs will at least rise more slowly and, in some cases, will decline.
For those interested in going beyond the bare minimum of quality improvement, a study of the Michigan model would be the place to start.
MOQC = Michigan Oncology Quality Consortium
PGIP = Physician Group Incentive Program