Innovations in Oncology Management - Part 3

Innovations in Oncology Management

PART 3 OF A SERIES

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Emerging Payment and Delivery Models

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he unsustainable rise in healthcare costs, the growing lack STAKEHOLDER PERSPECTIVE of access to healthcare, and the increasing disparities in care have contributed to the recognition that our existing Evolution of the Oncology Patienthealthcare system must change to meet the nation’s future healthCentered Medical Home ............. 6 care needs.

The current fee-for-service payment system has been criticized for An Interview with John Sprandio, MD depending too heavily on the volume of care delivered to patients Chief of Medical Oncology and Hematology B:8.375” rather than on the quality of care.1 Currently, providers are predomOncology Management Services T:8.125” inantly rewarded based on the number of tests ordered, drugs preDrexel Hill, PA S:7.625” scribed, and procedures performed, rather than on the clinical appropriateness of treatment decisions, the quality of care provided, and patient outcomes. As a result, several high-value services are inadequately reimbursed (if they are reimbursed at all). For example, versial, the ACA has been a catalyst for developing new healthMedicare and most private insurers will not reimburse physicians for care delivery and payment models that are designed to improve coordinating care by telephone or e-mail, but they will often pay for patient outcomes, decrease costs, and restructure reimbursement. duplicate tests or complications as a result of drug–drug interactions Building on this framework for reform, many federal, state, and that are caused by conflicting medications. In addition, reimburse- private programs have been developed to encourage providers to ment for patient education and self-management support services take increased responsibility for the cost and quality of care.3 has been poor or nonexistent, even if the services permit earlier Accountable care organizations (ACOs) and patient-centered disease identification or help to avoid expensive hospitalizations.1 medical homes (PCMHs) are 2 of the new models that have been tested across the country.3 The Centers for Medicare & Medicaid Services (CMS) continues to award grants to healthcare organizations, academic institutions, and others to develop innovative ideas that deliver better health, improve care, and lower costs for individuals who are enrolled in government healthcare programs, such as Medicare and Medicaid.3,4 The reforms that are taking place as a result of the ACA are affecting the business and clinical practice of oncology at the local level and will continue to do so in the future. Progressive oncology providers and administrators should consider the potential impact of In many cases, hospitals and healthcare providers lose revenue if these reforms on their practice and prepare to respond accordingly.5 they perform fewer procedures or lower-cost procedures.1 Furthermore, there are no financial incentives for physicians when their Accountable Care Organizations patients are doing well and do not require treatment. A growing The concept of the ACO was first discussed in 2006, and the recognition of this dynamic has led to today’s era of healthcare re- term became widely used when the ACA was signed into law in form, which aims to profoundly affect the way that healthcare is 2010.6 An ACO may be described as a formally organized entity delivered and financed.1 comprising physicians, hospitals, and other relevant health service In an effort to move healthcare reform forward, key pieces of professionals who have voluntarily joined together and contracted legislation have been enacted in recent years, most notably the with payer organizations to provide a broad set of healthcare serPatients, Science, and Innovation the foundation everything Patient Protection and Affordable Care Actare (ACA), which took of vices to their Medicare patients.7 we in do.

At 2Celgene, we believe inofan commitment to designed to deliver seamless, high-quality care for effect 2010.

Although some provisions it unwavering have been controACOs are

The current fee-for-service payment system has been criticized for depending too heavily on the volume of care delivered to patients rather than on the quality of care.

medical innovation, from discovery to development. Our passion is relentless—and we are just getting started.

Supported by funding from Celgene Corporation and Celgene Patient Support. Manufacturer did not influence content.

© 2014 Celgene Corporation

09/14

US-CELG140022(1)

Innovations in Oncology Management

PART 3 OF A SERIES

http://innovationsinoncologymanagement.com

TM

Emerging Payment and Delivery Models

T

he unsustainable rise in healthcare costs, the growing lack of access to healthcare, and the increasing disparities in care have contributed to the recognition that our existing healthcare system must change to meet the nation’s future healthcare needs.

The current fee-for-service payment system has been criticized for depending too heavily on the volume of care delivered to patients rather than on the quality of care.1 Currently, providers are predominantly rewarded based on the number of tests ordered, drugs prescribed, and procedures performed, rather than on the clinical appropriateness of treatment decisions, the quality of care provided, and patient outcomes. As a result, several high-value services are inadequately reimbursed (if they are reimbursed at all). For example, Medicare and most private insurers will not reimburse physicians for coordinating care by telephone or e-mail, but they will often pay for duplicate tests or complications as a result of drug–drug interactions that are caused by conflicting medications. In addition, reimbursement for patient education and self-management support services has been poor or nonexistent, even if the services permit earlier disease identification or help to avoid expensive hospitalizations.1

The current fee-for-service payment system has been criticized for depending too heavily on the volume of care delivered to patients rather than on the quality of care.

In many cases, hospitals and healthcare providers lose revenue if they perform fewer procedures or lower-cost procedures.1 Further­ more, there are no financial incentives for physicians when their patients are doing well and do not require treatment. A growing recognition of this dynamic has led to today’s era of healthcare reform, which aims to profoundly affect the way that healthcare is delivered and financed.1 In an effort to move healthcare reform forward, key pieces of legislation have been enacted in recent years, most notably the Patient Protection and Affordable Care Act (ACA), which took effect in 2010.2 Although some provisions of it have been controSupported by funding from Celgene Corporation and Celgene Patient Support. Manufacturer did not influence content.

STAKEHOLDER PERSPECTIVE Evolution of the Oncology PatientCentered Medical Home.............. 6 An Interview with John Sprandio, MD Chief of Medical Oncology and Hematology Oncology Management Services Drexel Hill, PA

versial, the ACA has been a catalyst for developing new healthcare delivery and payment models that are designed to improve patient outcomes, decrease costs, and restructure reimbursement.

Building on this framework for reform, many federal, state, and private programs have been developed to encourage providers to take increased responsibility for the cost and quality of care.3 Accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) are 2 of the new models that have been tested across the country.3 The Centers for Medicare & Medicaid Services (CMS) continues to award grants to healthcare organizations, academic institutions, and others to develop innovative ideas that deliver better health, improve care, and lower costs for individuals who are enrolled in government healthcare programs, such as Medicare and Medicaid.3,4 The reforms that are taking place as a result of the ACA are affecting the business and clinical practice of oncology at the local level and will continue to do so in the future. Progressive oncology providers and administrators should consider the potential impact of these reforms on their practice and prepare to respond accordingly.5

Accountable Care Organizations

The concept of the ACO was first discussed in 2006, and the term became widely used when the ACA was signed into law in 2010.6 An ACO may be described as a formally organized entity comprising physicians, hospitals, and other relevant health service professionals who have voluntarily joined together and contracted with payer organizations to provide a broad set of healthcare services to their Medicare patients.7 ACOs are designed to deliver seamless, high-quality care for

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FEATURE Emerging Payment and Delivery Models..................................................... 1

STAKEHOLDER PERSPECTIVE Evolution of the Oncology Patient-Centered Medical Home An Interview with John Sprandio, MD Chief of Medical Oncology and Hematology, Oncology Management Services, Drexel Hill, PA............................................ 6

The Lynx Group

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MISSION STATEMENT Oncology healthcare requires providers to focus attention on financial concerns and strategic decisions that affect the bottom line. To continue to provide the high-quality care that patients with cancer deserve, providers must master the ever-changing business of oncology. Innovations in Oncology Management ™ offers process solutions for members of the cancer care team—medical, surgical, and radiation oncologists, as well as executives, administrators, and coders/billers—including patient financial support services, health policy legislation, and emerging payment models.

Innovations in Oncology Management ™ is published by Engage Healthcare Commu­nications, LLC, 1249 South River Road, Suite 202A, Cranbury, NJ 08512. Copyright © 2015 by Engage Healthcare Communications, LLC. All rights reserved. Innovations in Oncology Management is a registered trademark of Engage Healthcare Communications, LLC. No part of this publication may be reproduced or transmitted in any form or by any means now or hereafter known, electronic or mechanical, including photocopy, recording, or any informational storage and retrieval system, without written permission from the publisher. Printed in the United States of America.

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Medicare beneficiaries, rather than Figure Enrollment in CMS-Sponsored ACO Programs as of April 2014 the fragmented care that has been common in fee-for-service–based medicine.8 Through this approach, the ACO program is designed to improve patient outcomes, promote accountability, coordinate care, encourage investment in infrastructure, and redesign care processes.9 CMS offers 2 ACO models––the Pioneer ACO Model and the Shared Savings Program––that are tailored to serve 2 different types of organizations.9 The Pioneer ACO Model is designed for healthcare organizations and providers who are already experienced in coordinating care for patients across care settings.10 The Shared Savings Program was developed to facilitate coordination and cooperation among physician groups, hospitals, and other participating providers to improve the quality of

Pioneer ACOs Shared Savings ACOs 2013 Cohort care for Medicare beneficiaries. The

Shared Savings ACOs 2012 Cohort Shared Savings ACOs 2014 Cohort Shared Savings Program rewards participating organizations that lower their growth in healthcare costs while ACO indicates accountable care organization; CMS, Centers for Medicare & Medicaid Services. meeting performance standards on Source: The Advisory Board Company. www.advisory.com/~/media/Advisory-com/Research/HCAB/Resources/2012/ Posters/Where-the-ACOs-are.pdf. Accessed November 10, 2014. the quality of care.9 Although the government-sponsored ACO programs are limited to patients with Medicare coverage, private insurers have entered Patient-Centered Medical Home into similar arrangements with local hospitals and physician netSpurred by the passage of the ACA, several states and healthworks that are modeled after the CMS program. For example, care organizations have implemented initiatives to transform their Aetna, a large health insurer with approximately 24 million memprimary care delivery systems to improve the health of their pabers, actively touts its proprietary Accountable Care Solutions tient populations and reduce costs. The PCMH, a leading care program for Medicare and commercial members.11,12 delivery model, seeks to promote quality by aligning incentives Since the passage of the ACA, ACOs have grown rapidly in across all healthcare stakeholders.16 popularity. As of April 2014, a total of 23 Pioneer ACOs and 343 The PCMH encompasses several core concepts. Foremost, it Shared Savings ACOs, which serve approximately 4 million is patient centered; that is, focused on the delivery of relationMedicare beneficiaries, have signed up to participate in the ACO ship-based primary care that looks at the whole person.17 It is 13,14 program (Figure).

Thus far, an estimated 428 provider groups also comprehensive: care is delivered by a treatment team comhave signed up to participate in the CMS-sponsored and private prising physicians, nurses, advanced practice nurses, physician payer–sponsored accountable care programs, accounting for apassistants, pharmacists, nutritionists, social workers, educators, proximately 14% of the US population.13 and care coordinators, depending on specific patient needs. In The ACO program continues to evolve. In October 2014, the PCMH model, patient care is coordinated within the mediCMS launched the ACO Investment Model, which seeks to procal home and across elements of a broader healthcare system. In mote accountable care in rural areas by offering prepayment of addition, the PCMH is accessible and responsive to patients’ shared savings in regions that have encountered challenges in needs and preferences. Finally, the PCMH shows a commitment making the upfront investment that is required for ACO particito continuous quality improvement by using evidence-based pation.15 At the same time, ACOs that joined the Shared Savings medicine and clinical decision support tools to guide shared Program beginning in 2012 are being required to transition to decision-making, engage in performance measurement and arrangements with increased financial risk, with the expectation improvement, and measure and respond to patient experiences that increased risk will lead to greater Medicare savings.15 and patient satisfaction.17

INNOVATIONS IN ONCOLOGY MANAGEMENT u 3

The PCMH seeks to reduce the degree of fragmentation that is inherent in the fee-for-service delivery model. Electronic data systems, health information exchanges, and registries have all helped to facilitate the transformation toward coordinated, patient-centered care. Perhaps more importantly, however, recent evidence suggests that organizational change is the central impetus for quality improvement in the PCMH model.18 As the US population ages and becomes more demographically diverse, the PCMH is well-suited to deliver high-quality, costeffective, efficient, and coordinated care to patients with chronic health conditions.19 In addition, evidence suggests that the teambased approach that is central to the PCMH and similar models may also help to alleviate projected shortages of primary care physicians in the coming years.20

The PCMH seeks to reduce the degree of fragmentation that is inherent in the fee-for-service delivery model.

In 2011, the National Committee for Quality Assurance (NCQA) initiated the Physician Practice Connections (PPC)PCMH Recognition Program, which recognizes practices that successfully use systematic processes and information technology to enhance the quality of patient care.21 The PPC-PCMH Recognition Program is based on meeting standards in a number of categories, including access and communication, care management, patient self-management and support, electronic prescribing, and performance reporting and improvement.21 Applying the Patient-Centered Medical Home Model to the Oncology Community The PCMH model is gradually being adopted by the medical oncology community.

In 2004, Consultants in Medical Oncology and Hematology (CMOH), a Pennsylvania-based community oncology practice, began to redesign its care processes and invest substantially in its information technology infrastructure.22 As a result of these efforts, the practice created a broad spectrum of patient services that enhanced the level of care coordination and the collection and evaluation of clinical data. In addition, CMOH demonstrated that the application of the PCMH model to oncology was effective in minimizing the unnecessary use of resources by lowering emergency department visits, reducing hospital admissions, and reducing the length of stay for admitted patients. CMOH became the first oncology practice that was recognized by the NCQA as a level 3 PCMH.22 Championed by the Community Oncology Alliance, the Oncology Medical Home (OMH) is an alternate model for providing coordinated, patient-centered oncology care.23 In the OMH, the oncology practice serves as the medical home, with the goals of (1) providing accessible, efficient, and affordable care; (2) implementing evidence-based treatment plans that strive for qual-

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ity outcomes; and (3) applying quality standards to ensure that patient care is continuously improved.23 With an eye toward integrated care and stakeholder alignment, OMH brings together oncologists, payers, insurance administrators, cancer care advocates, patient advocates, nursing representatives, and pharmacists to steer the initiative toward its goals.23 Another oncology-based PCMH model, COME HOME, was developed by the New Mexico Cancer Center (NMCC) under the leadership of its chief executive officer, Barbara McAneny, MD.24 The COME HOME program of comprehensive community cancer care is founded upon the core principles of active condition management, team-based care that is delivered by patientfocused interdisciplinary teams, enhanced access for patients, electronic data systems and decision support, and financial support for patients in need.24 The NMCC was awarded a series of CMS Innovation grants in 2011 to establish a proof of concept for the COME HOME model. The program is projected to produce overall Medicare cost-savings of $4178 per patient per year during 3 years, for a total net savings of $13.76 million; the bulk of these projected savings are attributed to averted emergency department visits and hospitalizations.24

Medicare Demonstration Projects

As the nation’s largest purchaser of healthcare services, Medicare continues to explore ways to control healthcare costs.

The ACA provides funding for a number of new demonstration projects to test the impact of innovative approaches that are intended to improve quality and efficiency and reduce costs.19 One novel payment mechanism that has received substantial attention is the concept of bundled payments, where providers receive a single payment for episode-based groups of related services rather than separate payments for each individual service.19 CMS is promoting bundled payment pilots through the Bundled Payments for Care Improvement initiative, in which organizations enter into payment arrangements that include financial and performance accountability for episodes of care.25 According to CMS, bundled payments can align incentives for providers (eg, hospitals, post–acute care providers, physicians), allowing them to work closely together across all specialties and settings. This approach is intended to encourage providers to deliver better coordinated and more efficient care and to eliminate ineffective and/ or unnecessary treatment.25 Value-based insurance is another payment-based approach that offers financial incentives to promote cost-effective healthcare services and consumer choices.26 Value-based health insurance benefit designs typically cover preventive care, wellness visits, and medications to control blood pressure or diabetes at a low cost or at no cost. By removing financial barriers to medication adherence and by encouraging self-management of chronic illnesses, health plans seek to save money by reducing future expensive medical procedures and unforeseen hospitalizations. Conversely, health insurers may also create disincentives (eg, high patient cost-sharing) for drugs that are not deemed to be cost-effective or procedures that are viewed as unnecessary or repetitive.26

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Payer Adoption of New Care Delivery and Payment Models

Evidence suggests that payers generally support collaborative engagement with providers within the framework provided by the new care delivery and payment models.27 As a first step, many payers have collaborated with network providers and/or third parties to develop clinical treatment pathways in oncology, with the goal of reducing clinical variation in care, improving care quality, promoting appropriate palliative care, and reducing costs, especially for end-of-life care.27 Many payers recognize, however, that additional action is required to foster true payer–provider collaboration, and are therefore taking steps to change incentives and reimbursement structures in oncology to ensure that all parties are aligned with the goals of healthcare reform.27 One survey of health plan medical and pharmacy directors confirmed that health plans are moving to implement ACOs and PCMHs.27 In the survey, payers generally agreed that the ACO and PCMH models offer structures and processes that would facilitate the delivery of coordinated oncology care, which would improve the quality of care and reduce wasteful or duplicated care.

As a result, nearly 60% of the surveyed payers planned to participate in ACOs and PCMHs in the near future. Of the payers who had formed a Medicare ACO, approximately two-thirds planned to expand it to include commercial plans.27

Conclusion

New care delivery and payment models, such as ACOs and PCMHs, seek to reward physicians and hospitals that provide high-quality, high-value care––thereby better aligning providers’ financial incentives with patients’ health outcomes.

Although these new models have the potential to encourage care coordination, improve the quality of care, and control costs, there are many challenges to implementing them; these challenges include obtaining provider buy-in, implementing new performance measurement and reporting systems, and establishing effective risk adjustment.

Despite the challenges, recent data indicate that these models are contributing to cost-savings. Recently, CMS issued quality and financial performance results that showed that Medicare ACOs have delivered more than $400 million in savings for the program. Furthermore, the data showed consistent improvement in quality measures, indicating a positive trend in patients’ experience and in the quality of care.28 Given these encouraging data, it appears that the momentum to transform healthcare delivery and payment will continue in the future. These fundamental changes are likely to have a profound effect on the business and clinical practice of oncology. u

References

1. Miller HD. Making the business case for payment and delivery reform. Robert Wood Johnson Foundation. www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf 411117. Accessed November 3, 2014.

2. Kaiser Family Foundation. Summary of new health reform law. www.kff.org/health reform/upload/8061.pdf. Accessed November 7, 2014.

3. American College of Physicians. Delivery and payment models. www.acponline.org/ running_practice/delivery_and_payment_models/. Accessed November 3, 2014.

4. Centers for Medicare & Medicaid Services. Health care innovation awards. http:// innovation.cms.gov/initiatives/Health-Care-Innovation-Awards/. Accessed November 7, 2014.

5. American Society of Clinical Oncology. The state of cancer care in America, 2014: a report by the American Society of Clinical Oncology. J Oncol Pract. 2014;10: 119-142.

6. Sullivan K. The history and definition of the “accountable care organization.”

October 2010. Physicians for a National Health Program. http://pnhpcalifornia.org/ 2010/10/the-history-and-definition-of-the-%E2%80%9Caccountable-care-organization %E2%80%9D/. Accessed November 7, 2014.

7. American College of Physicians. Accountable care organizations. www.acponline.org/ running_practice/delivery_and_payment_models/aco/. Accessed November 3, 2014.

8. Department of Health & Human Services. Summary of final rule provisions for accountable care organizations under the Medicare shared savings program. April 2014. www.cms.gov/medicare/medicare-fee-for-service-payment/sharedsavings program/downloads/aco_summary_factsheet_icn907404.pdf. Accessed November 5, 2014.

9. Centers for Medicare & Medicaid Services. Shared savings program. Updated March 11, 2014. www.cms.gov/Medicare/Medicare-Fee-for-Service-payment/shared savingsprogram/index.html?redirect=/sharedsavingsprogram/. Accessed November 4, 2014.

10. Centers for Medicare & Medicaid Services. Pioneer ACO model. http://innovation. cms.gov/initiatives/Pioneer-ACO-Model/. Accessed November 4, 2014.

11. Aetna. Models of collaboration. www.aetnaacs.com/models-collaboration. Accessed November 4, 2014.

12. Aetna. Aetna facts. www.aetna.com/about-us/aetna-facts-and-subsidiaries/aetnafacts.html. Accessed December 4, 2014.

13. Gold J. FAQs on ACOs: accountable care organizations, explained. http://kaiser healthnews.org/news/aco-accountable-care-organization-faq/. Accessed November 4, 2014.

14. The Advisory Board Company. Where the ACOs are. www.advisory.com/~/media/ Advisory-com/Research/HCAB/Resources/2012/Posters/Where-the-ACOs-are.pdf.

Accessed November 10, 2014.

15. Leventhal R. CMS launches new ACO model targeting underserved areas. Healthcare Informatics. October 15, 2014. www.healthcare-informatics.com/news-item/cmslaunches-new-aco-model-targeting-underserved-areas?page=1. Accessed November 4, 2014.

16. Watkins LD. Aligning Payers and Practices to Transform Primary Care. Milbank Memorial Fund. www.milbank.org/uploads/documents/papers/Milbank%20-%20 Aligning%20Payers%20and%20Practices%20-%20Exec%20Summary.pdf. Accessed November 5, 2014.

17. Agency for Healthcare Research and Quality. Defining the PCMH. http://pcmh. ahrq.gov/page/defining-pcmh. Accessed November 6, 2014.

18. Kern LM, Edwards A, Kaushal R. The patient-centered medical home, electronic health records, and quality of care. Ann Intern Med. 2014;160:741-749.

19. RAND Corporation. Payment reform and new models of care. www.rand.org/ health/aca/payment_reform_care_delivery.html. Accessed November 5, 2014.

20. Auerbach DI, Chen PG, Friedberg MW, et al. Nurse-managed health centers and patient-centered medical homes could mitigate expected primary care physician shortage. Health Aff (Millwood). 2013;32:1933-1941.

21. National Committee for Quality Assurance. NCQA Patient-Centered Medical Home. PPCR®-PCMH™. www.ncqa.org/Portals/0/PCMH%20brochure-web.pdf. Accessed November 6, 2014.

22. Sprandio JD. Oncology patient-centered medical home and accountable cancer care. Commun Oncol. 2010;7:565-572.

23. Community Oncology Alliance. Oncology medical home: improved quality and cost of care. September 22, 2014. http://coaadvocacy.org/2014/09/oncology-medicalhome-improved-quality-and-cost-of-care/. Accessed November 5, 2014.

24. Sanghavi D, Patel K, Samuels K, et al. Transforming cancer care and the role of payment reform: lessons from the New Mexico Cancer Center. August 2014. Brookings. www.brookings.edu/~/media/research/files/papers/2014/08/oncology%20care%20 payment%20reform/oncology%20case%20study%20%20august%202014%20final %20web.pdf. Accessed December 19, 2014.

25. Centers for Medicare & Medicaid Services. Bundled Payments for Care Improvement (BPCI) initiative: general information. http://innovation.cms.gov/initiatives/ bundled-payments/. Accessed November 5, 2014.

26. National Conference of State Legislatures. Value-based insurance designs. www. ncsl.org/research/health/value-based-insurance-design.aspx. Accessed November 7, 2014.

27. Greenapple R. Rapid expansion of new oncology care delivery payment models: results from a payer survey. Am Health Drug Benefits. 2013;6:249-256.

28. Centers for Medicare & Medicaid Services. Fact sheets: Medicare ACOs continue to succeed in improving care, lowering cost growth. November 10, 2014. www.cms. gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-11-10. html. Accessed November 22, 2015.

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STAKEHOLDER PERSPECTIVE

Evolution of the Oncology Patient-Centered Medical Home An Interview with John Sprandio, MD Chief of Medical Oncology and Hematology, Oncology Management Services, Drexel Hill, PA

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he delivery and financing of oncology care have changed rapidly in recent years, posing challenges for oncologists and their practice administrators. In an effort to improve healthcare quality, coordination, and efficiency, a number of novel payment mechanisms and cancer care delivery models are being developed and implemented. One such model, the Oncology Patient-Centered Medical Home (OPCMH), has been developed to help oncology practices enhance the value of cancer care. OPCMH was pioneered by John Sprandio, MD, and his colleagues at Consultants in Medical Oncology & Hematology (CMOH), a 9-physician medical oncology practice. CMOH was recognized by the National Committee for Quality Assurance as a level 3 Physician Practice Connections–Patient Centered Medical Home in 2010.

CMOH was also certified in 2010 by the American Society of Clinical Oncology via the Quality Oncology Practice Initiative.

Q

Q: What factors prompted CMOH to re-engineer its cancer care delivery processes more than a decade ago?

John Sprandio (JS): We were driven by the desire to enhance the consistency of care we were delivering and to differentiate ourselves in a competitive market. We took a critical look at our performance as a practice and whether we, as a group of 9 oncologists, were clinically integrated. We saw a great degree of variability in the way members of our care team engaged patients and the way our physicians delivered patient care. We needed to standardize and streamline variable processes that individual physicians had in place, but lacked a mechanism that could fix accountability to responsible members of the care team. As physicians, we also realized that we were bogged down by an increasing number of clinically irrelevant activities, such as inputting data into electronic medical record systems that did not match our workflow and working with third-party vendors seeking to implement payer-imposed pathways.

In addition, we were saddled by documentation burdens, messaging and workflow interruptions, and a lack of systems or models of teambased care to support clinical work. These and an increasing number of other “time-stealers” distracted us from our primary focus as physicians––to establish and maintain personal relationships with patients and to make complex medical decisions.

In order to refocus and prioritize our physician activities, we

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established 8 goals: (1) streamline our processes of care; (2) standardize roles and responsibilities of the care team members; (3) minimize clinically irrelevant physician activity; (4) engage patients and their families more fully and consistently; (5) fix accountability at the locus of control and responsibility within the care team; (6) select quality and practice performance metrics responsible for driving desired patient outcomes; (7) develop supportive information technology that facilitated this re-engineered model of care; and (8) deliver real-time data to our physicians to progressively improve performance.

Q

Q: How important was the role of technology in facilitating change?

JS: We implemented an oncology-specific EMR in 2004, but soon found that paper chaos was replaced by digital chaos. Poor information management was a huge barrier to meeting our stated goals. We were forced to spend more time in front of a computer screen than we spent in front of our patients. Our activities were focused on compliance and billing rather than on the collection and sharing of consumable, pertinent clinical data.

To address the disruption in workflow and process caused by the limitations of the available technology, we created a software application known as IRIS that overlaid our oncology-specific EMR. IRIS has evolved and serves as a platform for process standardization and workflow. IRIS facilitates the integration of workflow, data collection, data presentation, provider response to data, documentation, and communication. Physicians are able to concentrate on maintaining highly personal relationships with patients, have all data necessary to make increasingly complex medical decisions, and have the ability to do this more efficiently. We have accumulated more than 5 years of internal practice data documenting an improvement in the consistency of services, an improvement in quality, and a reduction in unnecessary resource utilization.

We continue to add features in response to physician information, communication, and documentation needs, engaging physicians to become more accountable for the quality and the cost of care.

Q

Q: How has the OPCMH concept continued to evolve? What changes has your practice made as part of that evolution?

JS: At the start of our journey in 2004, we did not have the goal

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of becoming a medical home. The Joint Principles of the PatientCentered Medical Home in primary care were not established until 2007.1 Our efforts were initially very physician-centric; however, the physician-centric activity evolved into a very patient-centered care capability.

We will continue to evolve IRIS from a technology and functionality perspective. On the technology side, we are working with partners to interface IRIS with other EMR vendors and to enhance analytic capabilities.

Methods of data collection and distribution are evolving; we are focusing on data that are reflective of patient activities that are complementary to the practice of PCMH-related service capabilities, the documentation and tracking of comorbid conditions, and the sharing of pertinent information directly to and from the oncology care team and other physicians responsible for patients’ comorbid conditions.

Patient engagement is evolving, and technology is playing a major role. Two-way patient portals are facilitating communication: they enhance patient ability and accountability for reporting symptoms in a timely fashion, educate patients about what to report, and give patients an avenue to clinical care.

Enhanced patient engagement and education are the cornerstones of the OPCMH model. These activities will evolve through continuous process improvement and through the progressive application of technology.

Q

Q: Community oncology is under tremendous financial pressure today. How has the implementation of the OPCMH concept helped to keep your practice fiscally competitive?

JS: Our practice went through a difficult period. When our patients experienced more complete and consistent office visits, resulting in less office visits per chemotherapy patient per year, fewer emergency department visits, fewer hospital admissions, and less chemotherapy utilization at the end of life, we as a practice experienced less revenue. We successfully reformed the way we delivered care, but we did it in a fee-for-service environment that did not recognize the quality or the level of service. Thankfully, oncology payment reform is now catching up with care delivery innovation. There are a number of examples nationally that have shown early promise. In the recently proposed Oncology Care Model, the Centers for Medicare & Medicaid Services will recognize the economic value of true practice transformation.

Early in 2014, we secured a contract with our largest payer. This contract, along with another payer contract (in its fourth year of operation), covers approximately half of our patient base. We expect to gain ground economically in the second half of this year when we can hopefully opt into the Oncology Care Model for a large portion of our Medicare patients.

Q

Q: How has the role of nurse practitioners (NPs) evolved at CMOH since the implementation of the OPCMH? JS: Our NPs are deeply embedded in the care team, with defined but flexible roles and responsibilities. Our NPs work in close partnerships with the oncologists.

I depend on my NP tremendously, but I also have full oversight and visibility with every action because of the systems that we have developed. This results in a collaborative, learning relationship that drives consistency of care.

Q

Q: What are the roles of the practice administrator and nonclinical support staff in supporting operations at CMOH? In the OPCMH setting, how is business management different from traditional practice models?

JS: Practice administrators and nonclinical support staff play a critical role. They must understand the OPCMH working model and the goals we are striving to achieve. There is also a reassignment of roles and responsibilities; for example, we trained administrative assistants to become lay patient navigators who are responsible for scheduling every appointment and tracking them to completion.

We have a well-scripted patient orientation intake process with dedicated staff who align our patients’ activities with our patient-centered practice model. Our billing specialists have become financial counselors who serve as the portal to the patient’s ever-changing benefits and rising out-of-pocket expenses. It is their responsibility to coordinate assistance for patients in need.

As care delivery processes evolve on the clinical side, there are complementary and supportive changes on the administrative side, and we rely on nonclinical staff to keep pace with the changing needs of our physicians, patients, and insurance regulatory changes.

Q

Q: How do you see the OPCMH model continuing to evolve in the next several years? What will be the drivers of change?

JS: With an oncology PCMH-like model in place and having technology-supported standardized processes of care as a foundation, we envision the enhancement of data collection and presentation, and the flow of progressively accurate and personalized patient information among all the stakeholders who are involved in caring for this complex patient population.

Our practice transformation company, Oncology Management Services (OMS), is in many ways contributing to the evolution of the clinical model and the associated value-based payment reform needed to align patient and provider activities. OMS provides a spectrum of services that includes practice assessments, facilitation of transformation, clinical tools, and technology support.

EMR platforms may soon open up to innovation, similar to our IRIS oncology software application. We can anticipate the expansion of technological capabilities to help physicians execute care more consistently and efficiently and move past the chaos that often defines the physician work environment today. I am very excited about the future of oncology care and the practice of medicine in general. u

Reference

1. American Academy of Family Physicians. Joint principles of the patient-centered medical home. www.aafp.org/dam/AAFP/documents/practice_management/ pcmh/initiatives/PCMHJoint.pdf. Accessed February 5, 2015.

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