Rising Costs and Fragmented Care
Survival for cancer patients in the United States ranks among the highest in the world. Despite the demonstrated success of the US cancer delivery system, government and private payers are forcing changes to the delivery of and payment model for oncology care, primarily due to the rising cost of cancer treatment. From 2001 to 2005, the annual cost of cancer treatment was approximately $48 billion per year. In addition, it is estimated that while oncology patients under active treatment represent only 1% of a payer’s patients, the care of these patients accounts for approximately 10% of costs.
It is likely that fragmented care is one driver of these higher costs, and it may also be hindering optimal outcomes. Opportunities to evolve and improve the delivery of cancer care certainly exist. Although metrics and processes through which to measure value and evaluate outcomes are sparse, surely who drives the process of change, and for what reason, will substantially affect the overall care that patients receive. We believe that physician-led change will lead to optimal outcomes since it is physicians who best understand the needs of patients and the actual process of care delivery.
The patient-centered medical home model has emerged in the primary care arena as a partial solution to fragmented care delivery. In the primary care setting, key features of this model include open access, enhanced care coordination, comprehensive care, and sustained personal relationships. Many of these concepts have been incorporated into the Oncology Patient-Centered Medical Home™ (OPCMH) model by Consultants in Medical Oncology and Hematology, PC (CMOH), a private practice in southeastern Pennsylvania. CMOH became the first oncology practice in the nation to achieve level III recognition from the National Committee for Quality Assurance (NCQA). We will describe this model as it currently exists and discuss opportunities to more broadly expand it into the current landscape of oncology. We believe this model represents a holistic solution to many challenges facing oncology, including issues of cost control, quality assurance, outcome measurement, and process improvement.
An Overview of the Oncology Medical Home at CMOH
Within the oncology medical home model at CMOH, each patient is managed by a physician-led care team. When the patient is diagnosed with a malignancy, the practice becomes the central coordinator of care throughout all phases of treatment. These include surgery, radiation therapy, chemotherapy, and later survivorship. Many non-oncologic medical issues continue to be managed by the patient’s primary care physician, and intense communication between the oncology team and the primary care team is essential. Achievement of level III NCQA recognition required that nine criteria be met:
• Increased patient-physician communication and increased communication with other treating physicians (primary care, surgery, radiation oncology).
• Patient tracking and registry functions, including reminders for preventative screenings.
• Care management and adherence to nationally accepted, evidence-based standards of treatment.
• Patient self-management and support to avoid disease- and treatment-related complications.
• Electronic prescribing and physician order entry.
• Test tracking and patient compliance monitoring.
• Tracking of referrals.
• Performance measurement within the practice and modification of process-of-care or services to improve specific targeted outcomes; this is a continuous process.
• Electronic communication portals for patients and referring physicians.
In applying these principals to oncology care, CMOH focused on the following:
• Standardization of the process of patient evaluation.
• Use of patient navigators to coordinate all aspects of cancer-related evaluation and services.
• Promotion of an interdisciplinary approach to management.
• Emphasis on patient education, engagement and compliance.
• Broadened patient access allowing for symptom management through extended hours, telephone triage, and availability of on-call physicians.
• Facilitation of accountability for care delivery at the physician-patient locus.
The creation of customized software was integral to the ability to execute the enhanced model of care. The customized IRIS™ software developed by CMOH as an overlay to an oncology-specific electronic health record (EHR) allowed for the formatting, standardization, and collection of essential patient management and utilization data. Examples of these software enhancements included 1) immediate completion of standardized documentation, 2) longitudinally recorded symptoms prompting important clinical decision making, 3) standardized assessment and documentation of Eastern Cooperative Oncology Group (ECOG) performance status with each visit, 4) changes in disease and performance status helping guide end-of-life care discussions.
The responsibilities of the CMOH-trained patient navigators included gathering clinical data, scheduling tests, scheduling appointments with primary care physicians and specialists, and directing patients to community support services. Proactive patient engagement was imperative. This included an emphasis on early intervention via utilization of the OPCMH telephone triage system to avoid the need for emergency room (ER) evaluations. CMOH developed standardized symptom management for a number of common clinical problems: dehydration, diarrhea, insomnia, and nausea and vomiting. This created a uniform approach to early symptoms that commonly lead to potentially avoidable complications.
Patient performance status became a key metric for decision making, and it assisted physicians in determining eligibility for chemotherapy administration on a given day. A decline in performance status to ECOG 3 triggered reassessment for potentially reversible conditions or discussion of hospice services and end-of-life care.
Adherence to clinical guidelines based on National Comprehensive Cancer Network (NCCN) and American Society of Clinical Oncology (ASCO) recommendations was encouraged by building these into the treatment careplans in the EHR. Guideline adherence was tracked at both the physician and practice level.
Multiple benefits have been demonstrated through the use of these efforts to build an “oncology medical home” at CMOH. Three quarters of all clinical calls have resulted in symptom management at home. One tenth of calls have prompted an office visit within 24 hours. Less than 5% of calls have resulted in an ER evaluation. The number of ER visits per chemotherapy patient per year has declined by 65% since 2006 to less than 1, a rate less than half that reported in another large commercially insured population. The rate of hospitalizations per chemotherapy patient per year has declined by 43% since 2007.
The Future of the Oncology Medical Home Model
For several reasons, the oncology medical home model represents a logical platform on which to build a more modern, value-oriented, outcome-based cancer care delivery system. The model starts with services that many oncology offices are already providing: overall care coordination, appropriate treatment planning, in-office chemotherapy coordinated by the oncology care team, enhanced access via telephone triage, and assistance with the transition to palliative and hospice care. The OPCMH model can help clarify the essential services oncology practices provide and can facilitate dialogue with government and commercial payers. The model retains in-office chemotherapy administration as an essential value-based service. It goes beyond the current practices of most offices by standardizing processes, measuring guideline adherence and outcomes, and tracking rates of ER utilization and hospitalization.
Many current programs created to reduce spending in oncology focus on drug utilization. The oncology medical home places more appropriate emphasis on areas in which oncologists can truly affect costs, such as ER utilization and hospitalization rates. Currently, the cost of hospitalization is very near or exceeds the cost of drugs in cancer care (Ira Klein, Aetna Medical Director, personal communication, November 2010). An analysis by the Community Oncology Alliance and Avalere Health revealed that Medicare payments for infusion codes covered only 57% of the actual costs for calendar year 2008. Improved care coordination, open access, and avoidance of potential complications can be expected to lower these costs. Whereas the rising cost of oncology pharmaceuticals attracts a great deal of attention, it is essential to recognize that oncologists do not set the price of therapeutics. Furthermore, it is our responsibility to our patients to offer uniformly appropriate treatment options. The oncology medical home model helps to accomplish this by including the use of appropriate guidelines and by using the measurement of patient performance status to help guide eligibility for chemotherapy.
Payers must recognize true practice expense and the value of the disease management and cognitive services inherent in the OPCMH model. In order for other practices to transition to the OPCMH model, it is critical that appropriate private payer and government support be agreed upon prospectively. Providers, patients, and the NCQA agree that the OPCMH model should be a focus in the reengineering of our health care system; the question is whether or not the payers agree.
Many current quality metrics in oncology are retrospective and require time consuming data abstraction from the medical record. The OPCMH quality metrics embedded in the EHR would allow for real-time feedback on performance and the potential to improve the quality of care at the time of service. Furthermore, the proposed Centers for Medicare and Medicaid Services (CMS) rule for Accountable Care Organizations (ACOs) surprisingly contains almost no quality parameters for cancer care delivery, with the exception of preventative screening. This is very concerning since cancer is the second leading cause of death and represents a high-cost area of medical care. Moreover, few safeguards exist within the ACO quality measures to ensure that achievement of the cost savings mandated by the ACO model is not accomplished by withholding appropriate care for cancer patients.
In summary, the oncology medical home has the potential to be a holistic solution to improving cancer care delivery. Instead of attempting to provide individual solutions to the problems of quality, outcome measurement, avoidance of ER visits and hospitalizations, and improved care coordination, the oncology medical home can create both the structure and process to address these issues simultaneously. Furthermore, it places the responsibility for and authority over cancer care delivery where it belongs: in the hands of those who are actually accountable for the delivery of cancer care – the medical oncologists. For the OPCMH model to be sustainable, however, it must be shepherded carefully through the complex process of policy creation and reimbursement reform.