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Payers Pushing for Medical Home Concept

Butcher, Lola


While the Community Oncology Alliance is supporting a multi-stakeholder approach to developing an oncology medical home model, many payers across the country are stepping out with their own versions of the concept.

“Of course, everyone defines ‘medical home’ differently,” said Stuart Genschaw, Executive Director of Cancer & Hematology Centers of Western Michigan.

His practice—16 physicians in four locations—entered into a medical home contract with Priority Health, one of its largest private payers, on Feb. 1. While the details are still being worked out, the insurer is offering financial support to help him make the transition.

“There are really two key elements to this medical home model,” said John Fox, MD, Associate Vice President of Medical Affairs for Priority Health and a member of COA's steering committee. “One is care reform: how we are going to change the way care and services are delivered. A second is payment reform: how we are going to pay for this differently than we have done before.”

Meanwhile, many of the national insurance companies are introducing their own ideas for oncology practices as well. Aetna, for example, offers a health information exchange technology that would allow oncologists to avoid some of the expense associated with the build-your-own-medical home model pioneered by John Sprandio, MD, at his practice in suburban Philadelphia. (See “Inside Look: The First Oncology Medical Home,” starting on next page).

Ira Klein, MD, Senior Medical Director for Aetna, says the use of that technology or a certain medical home business model is not his company's end goal. Rather, Aetna intends to replace all its buy-and-bill contracts with arrangements that tie payment to the physicians' ability to control the overall cost of care while delivering good patient outcomes.

“We as a company are not going to get hung up on terminology about ‘medical home’ or ‘non-medical home,’” said Klein, who also serves on COA's steering committee. “Any contract we make that involves the use of [evidence-based] guidelines and pathways with reporting back to us on performance would automatically have those financial terms in there because we will be measuring hospital bed days, ED visits, and other costs.”

The payers' motivation is simple: They want physicians to take responsibility for controlling the costs and quality of cancer care and, when they succeed, to be rewarded financially. The benefit to insurers is that, if oncologists thrive financially, they will stop selling out to hospitals, where the overall cost of cancer care is much greater.

“I can tell you that all the other national, publicly traded companies and most of the regional Blues plans and a lot of the independents are all on board with saving community oncology,” he said. “We want this to happen.”

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The Big Picture

While health reform is unfolding in all areas of the health care industry, oncology is getting special attention because of its high cost. Oncology costs are rising at double the rate of medical inflation, he said.

“Oncology costs have become a real burden to the economy, and for us at Aetna, it represents 10 to 11 percent of our total medical spend. If you look at the leader in medical cost, which is oncology, it's only logical that we would devote resources to think about how to do it better.”

He sees the oncology-specific medical home as one step on a continuum of changes that oncology practices will face in the foreseeable future.

The first step is the adoption of cancer care pathways to standardize the treatment of patients with a given disease state. While many oncology practices do not yet use pathways, payers will increasingly insist on standardized treatment protocols as an essential element of quality care.

The second step, he says, is the oncology-specific medical home, in which oncologists take responsibility for coordinating a patient's health care services and reducing the use of hospitals and emergency departments.

“We're all moving now to oncology patient-centered medical homes as a way to improve the holistic aspect of care,” he said. “Once physicians have the office workflow down and, once we have payment methodology set up, they can then jump into the new ACO world and become a player in integrated delivery systems.”

In the “ACO world,” an oncologist participating in an accountable care organization would not necessarily have to be in the ACO, but would associate in some way with entities that assume the financial risk—and potential reward—for the cancer care needs of a defined population of patients

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Stepping Beyond Pathways

In Michigan, Priority Health has signed medical home contracts with several leading oncology practices. Many Michigan oncology practices have been using cancer care pathways for years, but Fox says oncologists need to deliver—and be paid for—a wider range of services.

“Pathways, from our vantage point, simply focus on controlling drug costs, and we thought there was a real opportunity to not be drug-focused, but patient-focused,” he said. “What can we do to enhance the overall experience and outcomes and impacts to the cost of oncology beyond simply drugs?”

Through medical home contracts with Priority Health, oncology practices are required to comply with standardized treatment regimens of their own choosing; to elicit, document and follow their patients' advanced care planning goals; and to help patients manage their symptoms more effectively.

“The expectation is that through better access to after-hours care, the telephone triage process, same-day or next-day services, better patient engagement and education tools, and more standardized delivery of those tools that we can actually reduce avoidable ED visits and hospitalizations,” Fox says.

Priority Health pays oncologists and their colleagues in the medical home for the professional services they provide, plus a monthly case management fee for every patient who is getting active treatment—either intravenous or oral, as long as it is provided through the physician's office. The physician's drug purchases are reimbursed at cost.

At the end of the year, oncology practices that have reduced Priority Health's hospital and ED costs will receive “shared savings,” meaning that the insurer will share part of the savings with the practice.

“The upside for me…is that we are going to be rewarded if our admission rates go down,” Genschaw said.

His practice is taking several steps to become a medical home practice:

  • Improving patient education delivered by nurse educators. Patient education will be standardized and documented in patient records.
  • Introducing a patient engagement program in which patients are trained to recognize troubling symptoms before they become an emergency. “We're going to have more of a call-me-first policy,” he said.
  • Providing patients with around-the-clock access to a nurse. “They will get a real oncology nurse who works for Cancer & Hematology who will be able to pull the patient's information up on the [electronic medical record] and respond to their concerns,” he said. “If the patient needs hydration, we will say, ‘We're going to schedule you at 7 am in the morning; a nurse will be there to see you and you'll get hydration.”
  • Adjusting the office schedule. More appointments will be available in morning hours for patients who need immediate care.
  • Developing a protocol for advanced care planning discussions within 60 days after a patient's treatment begins.
© 2012 Lippincott Williams & Wilkins, Inc.
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