In 2012, the federal Centers for Medicare and Medicaid Innovation (CMMI) sought to support oncologists in addressing what CMMI considered to be among the failings in cancer care— namely, fragmented care, suboptimal outcomes, high costs, and patient dissatisffaction. To remedy these weaknesses, CMMI awarded $19.8 million to Innovative Oncology Business Solutions (IOBS), Inc, in Albuquerque, NM. Barbara L. McAneny, MD, an oncologist, is the CEO and chief medical officer for IOBS, the company she launched to manage the Community Oncology Medical Home (COME HOME) program.

Board certified in internal medicine, oncology, and hematology, McAneny is a founding member of New Mexico Oncology Hematology Consultants and a former president and CEO of New Mexico Cancer Center, one of the state’s largest oncology practices.

The practice has a staff of 208, including 10 medical oncologists, 3 radiation oncologists, 1 hospitalist, 2 internists and a retired emergency department physician. We asked her to explain what outcomes the COME HOME program expects to deliver.

Congratulations on the CMMI grant, under which you and oncologists in 7 practices in 6 states are testing the COME HOME concept. CMMI has set some rather high goals for the program, saying it expects the savings after 3 years will total $33.5 million. Can you discuss the outcomes you’ve seen so far?

Yes. To date, we have implemented the triage pathways in all 7 practices. And, we have developed and are implementing our own diagnostic and therapeutic pathways. Even though it’s early to get patient outcomes, we’re beginning to see hospitalization rates from a couple of practices drop by as much as 30 percent. So that is excellent.

Are we on track to save what CMMI projects?

Yes. We don’t know that yet. One of the difficulties we’ve faced is getting data from the federal Centers for Medicare & Medicaid Services (CMS). That data lag well behind the years when CMS collects the data. We’re starting to get files from 2012 and early 2013. Therefore, we are unable to compare real-time data with those from other practices. Ultimately, we want to compare what Medicare spent for cancer care in the past and what we are spending now.

 While hospitalizations are down, do you know if imaging in emergency department visits are down as well, both of which are costly? McAneny: Yes, both of those components are very costly and those numbers do not include the costs of imaging in the emergency department (ED). Often when a cancer patient goes to the ED, the physicians almost automatically order images. Then if the patient needs imaging of a tumor, insurers may deny it because the patient just had one in the emergency department. So, that’s not helpful.

 Is that situation indicative of the need for medical homes if oncologists can coordinate care more efficiently?

 Exactly. That’s one reason we do so much patient education. We’ve discovered that in some practices, patients don’t want to bother the doctors. They would rather sit home and feel miserable than call us. So we tell them, “Please, bother us! We want to know how you’re doing.” That’s one lesson we learned early: we need better patient education.

Another reason patients don’t come in is that they want to avoid making another co-payment. These are a barrier to care because these patients are in Medicare Advantage plans and they have deductibles and coinsurance. We can’t waive those payments because we are required by law to collect that money. Yet a number of people go bankrupt from the high costs and most of them are insured. So, they don’t come to the office when they should but if it gets to be 10 pm and they still feel bad, then they may need to go to the emergency department. Unfortunately, the co-payments and deductibles are even higher there, and that’s what we’re trying to avoid. When patients are very co-payment sensitive, it means the system isn’t working.

Before applying for the CMMI grant, did you do any research to know what you could accomplish for patients and what you might save?

We didn’t do research exactly. We just took what I had developed in my own practice. Ever since we started the practice in 2002, we’ve been trying to figure out how to deliver highly efficient care. Patients are trying to navigate the system without any assistance because typically an oncologist will tell a patient to get some imaging done or meet with a surgeon and then can call to schedule an appointment. Then the patient has to figure out how to schedule a scan and get prior authorization from the insurance company. That delays treatment for maybe 2 months, and the patient gets discouraged and the tumor gets worse.

We found that cancer patients cannot cope with that system. So we schedule everything for them and give them a list of appointments to follow. And we give them the name of someone on our staff and a phone number to call if they have questions. Now they get to know the people on our staff and everything they need outside of our office gets done.

Did you also extend your office hours so that patients could come in if necessary rather than go to the hospital?

Yes, we did. For example, originally we had patients going to the hospital on weekends to get their Neupogen injections because we weren’t open on weekends. But then the patients would say they had to wait several hours for an injection that takes 10 minutes to administer, and the copayment was 3 times higher. As we know, everything is more expensive in the hospital.

So we started doing a shot clinic. For that, we would ask patients if they had any fever in the past 24 hours. If they had, we’d see them for antibiotics. We started doing this all the time, even on Saturdays, Sundays, and holidays. Our patients are poor people. They can’t afford those co-payments. And they can’t afford the transportation. Plus, going to the hospital is hard on people. Our shot clinic worked well enough so that we were saving a significant amount of money. And because we have a good electronic health record system, we could show how much money we were saving compared with national averages for hospitalizations and ED visits. We saw we could deliver better care and that’s what led us to apply for the CMMI grant. The award allowed us to expand what we do from just the shot clinic to after-hours and weekend clinics. We have a retired ED physician covering those Saturday and Sunday clinics.

 Did you have to transform your practice to make sure you covered these additional hours?

 We had to switch our practice mentality from ‘We’re busy all day and don’t want another patient coming in because we’re slammed’ to ‘How do I get this patient what he or she needs when needed, which is often right now, meaning today?’ We developed same-day appointments and the grant allowed us to expand our hours into the evening and to expand what we do on weekends. The grant does not pay for anything that is billable to Medicare but it helps us stay open until 8 pm every night.

Now if we see 6 patients between 5 and 8 pm, there’s not enough payment in the Evaluation & Management (E&M) codes to pay for the staff and the infrastructure needed to see 6 patients. But if those 6 patients called the office, got a recording and were told to go the ED, then the costs would be much higher than what CMS pays for 6 E&M codes. If patients call the office after hours, they’re sick. When they do, the recording in most offices says, ‘If this is an emergency, call 911.’ So now 6 patients are going by ambulance to the ED or getting admitted. But because we stay open later, we’ve saved the system a huge amount of money.

The problem is that those savings go to the payers and not to us. So, we’re tracking the numbers through Medicare claims data so we can show these savings at the end of the program.

 Did you have to revise your triage system so that patients wouldn’t automatically go to the ED?

Yes, we did. There’s no more recording at all. Instead, we have phone operators and triage nurses who follow the triage protocols that I wrote. If a patient calls and says any version of, “I’m sick,” then the phone operators ask 4 questions to determine that patient’s level of sickness. If it’s very serious, they have a nurse talk with the patient immediately. If the problem is not life threatening, the triage nurse calls the patient back within 2 hours. Because the triage nurses have the power of the schedule, the patients get right in with us.

 That sounds like the kind of initiative health insurers would want to use. Have any expressed interest in what you’re doing?

 Yes, health insurers are interested. But for now, they like being free riders. Among physicians at upper levels in insurance companies, however, a program like ours makes perfect sense. They recognize that the insurers need to share the savings with us. We’re creating those savings by being more efficient.

Unfortunately, the people involved in contracting and negotiations are still trying to get the lowest possible price from us. They don’t get that if they drive independent practices out of business, they will have to contract with hospital-based physicians and then pay much more for the same care. We hope to show that through the savings we’re generating, we can help insurers and Medicare save money. Then maybe they’ll invest more in delivering care efficiently.

Articles

In an interview with Oncology Business Management, Barbara L. McAneny, MD, explains how
the program will address fragmented care, suboptimal outcomes, high costs, and patient dissatisfaction.

By Joseph Burns

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COME HOME Program Set to Save $33.5M Over 3 Years