Amid Calls for Standardization, Oncology Medical Homes Grow

John Sprandio, MD

For the past 10 years, John Sprandio, MD, has been standardizing care delivery processes for cancer patients.

This effort has transformed his practice in Drexel Hill, Pennsylvania, into a patient-centered medical home. In 2010, his Oncology Patient-Centered Medical Home (OPCMH) became the first cancer practice that the National Committee for Quality Assurance certified as a PCMH. In the same year, the American Society of Clinical Oncology’s Quality Oncology Practice Initiative (QOPI) also certified the practice.

“About a decade ago, it became clear that we needed to standardize our care to minimize variation. We had to improve patients’ level of engagement in their care and reduce the barriers that physicians face when trying to deliver more consistent care in terms of quality and costs,” said Sprandio. “That’s why we streamlined processes and removed clinically irrelevant activities from the physicians so they could concentrate on delivering patient care. We developed a physician-led care team model of practice and then held members of the team responsible for the care they delivered,” Sprandio explained.

In 2010, Aetna and Innovent Oncology, a program supported by The US Oncology Network, started developing a similar model of care for cancer patients in Texas. Just as Sprandio does, these programs use evidence-based guidelines to reduce variation in care delivery. Nurses supplement the work of oncologists, thus helping to improve cancer care quality and reduce the side effects that patients experience.

CMMI

The oncology medical home has attracted the interest of the federal Centers for Medicare and Medicaid Innovation (CMMI), which awarded $19.8 million in 2012 to Innovative Oncology Business Solutions, Inc, in Albuquerque, New Mexico, to implement and test community oncology medical homes in 7 practices in 6 states.

At the time, CMMI estimated that the 3-year savings from the project, called the COME HOME program, would reach $33.5 million. The program will serve patients with breast, colon, lung, pancreatic, and thyroid cancers, and those with lymphoma and melanoma.CMMI wants oncologists to address some of the failings in the way care is delivered to cancer patients, such as the fragmented nature of care, suboptimal outcomes, high costs, and patient dissatisfaction. “Through comprehensive outpatient oncology care—including extended clinic hours, patient education, team care, medication management, and 24/7 practice access and inpatient care coordination—the medical home model will improve the timeliness and appropriateness of care, reduce unnecessary testing, and reduce avoidable emergency room visits and hospitalizations,” CMMI said when awarding the funds.

Sprandio’s OPCMH aims to meet these same attributes. Under contracts with Independence Blue Cross and Aetna, the OPCMH serves Medicare Advantage and commercial members. Sprandio also has a contract with Keystone First to serve Medicaid patients. These 3 contracts cover 54% of the practice’s patients.

“Many complications that cancer patients experience related to disease or therapy are potentially avoidable. If you can avoid those problems, you decrease unnecessary resource utilization without restricting care,” he explained. This is the heart of patient-centered care.

“We’re not restricting or rationing care but instead we engage patients and encourage our physicians to target potentially avoidable complications, provide better service and track internal performance on a significant scale,” he explained.

“The physicians accept accountability for the success of their efforts because their goal is to become value-based providers and not volume-based providers.”

To improve patient outcomes, OPCMH physicians follow 22 internal performance metrics. Streamlining processes allowed the practice to increase patient volume by 30% and reduced the number of full-time equivalent staff per physician, Sprandio said.

To avoid unnecessary emergency department (ED) visits and inpatient stays, the practice introduced algorithms for a telephone triage system to get patients the care they need when they need it.

“For years we’ve been interested in reducing ED utilization because it’s inconvenient for patients and a source of bad decisions, such as unnecessary imaging, laboratory testing and other interventions,” Sprandio explained. “Nervous ED physicians were admitting patients in the middle of the night without calling us. We wanted to change that.”

Patient Engagement

“So we went on a patient engagement rampage and indoctrinated our patients with the idea that we are the point of triage for any symptom they have at any time, excluding emergent cardiovascular, orthopedic, or central nervous system events,” Sprandio said. “Now patients use our telephone triage service to get same-day visits or for us to provide management at home.”

Among OPCMH patients who called with symptom-related complaints last year, 86% were managed at home, 4% were seen that day, 3.4% of patients were seen the following day based on their level of illness, and only 2.4% resulted in ED visits. The result was a 70% drop in ED visits among patients.

By combining the telephone triage results with that of other components of the OPCMH, Sprandio estimates that the practice reduced hospital admissions by 50%. “These reductions in utilization were achieved in the most vulnerable subset of the patient population, those who are receiving intravenous chemotherapy,” he added.

A study published in 2010 showed that the ED use rate among chemotherapy patients nationwide was 2.0 visits annually. “Our rate in 2013 was 0.741 ED visits per chemotherapy patient per year,” he said.

The Center for Cancer and Blood Disorders

The Center for Cancer and Blood Disorders in Fort Worth, Texas, uses a similar approach with its PCMH, according to CEO Barry Russo. The center is one of the practices in the COME HOME program.

“Compared with standard care for most cancer patients, our approach to patients in our medical home is to give them much more intense oversight. Case managers keep track of patients’ treatment so we can keep them out of the ED and out of the hospital because those are the 2 largest expenses that we have,” Russo said.

The 20-physician practice has about 70 patients in the COME HOME program and has a contract with Aetna that started in March to develop an oncology medical home for 15 patients, he said. It also has a 4-year contract with UnitedHealthCare for an episode-of-care program that began in 2010.

“In the United fee-for-episode program, we followed specific clinical pathways with the intent that standardization would reduce costs and improve quality. The same is true with the COME HOME and Aetna programs,” Russo said.

Just as Sprandio did in his practice, Russo’s practice redesigned its triage program. “The revamped triage program is making a significant difference in how we manage patient complications and even patient satisfaction,” he said. “In addition, we have extended hours until 8 each weeknight, and we’re open on Saturdays and Sundays. All these initiatives give patients more options to see one of our physicians besides going to the ED. By keeping ED visits down, we can show that we’re catching patients’ issues early and solving problems for them.”

The practice also has nurse case managers call chemotherapy patients to ask about symptom management. “If these patients are not feeling well or running a fever, our case managers advise them on how to handle their symptoms and prevent them from becoming acute episodes,” he said.

Such aggressive management of cancer patients requires an investment of time and money, said Marcus Neubauer, MD, the medical director of Oncology Services and Innovent Oncology for McKesson Specialty Health and The US Oncology Network. The US Oncology Network has a medical home project with Aetna for Medicare Advantage members.

Innovent Oncology

Aetna pays Innovent Oncology a fee to help cover the cost of enhanced clinical services for cancer patients, according to Michael Kolodziej, MD, Aetna’s national medical director for oncology solutions.

“Some payers are willing to sponsor innovative payment models such as oncology medical homes,” he said. “Innovent Oncology is one such program that enhances quality care and uses the practice EMR to extract data and measure performance. The program recognizes the major cost drivers of cancer care and offers solutions.

One cost driver is the highly variable use of services such as chemotherapy. Physicians in the Innovent program follow evidence-based clinical pathways. Adherence rates are documented and then reported to the payer sponsor. We also receive claims data on hospitalization rates from the payer and those rates are compared to a control group. One of the goals of the program is to reduce avoidable hospitalizations.”

Such innovative models of cancer care have captured the attention of institutional oncology programs and community practices, according to Sprandio. Kolodziej agrees, saying, “Everyone is looking at where the opportunities are to lower costs and improve quality. What we need now is a lot of good dialogue between payers and providers about performance metrics.”