Institute for Value-Based Medicine: Philadelphia Region, Fall 2019

Facilitating the Qualitative Improvement of Oncology Through Value-Based Care

As he started the meeting alongside cancer care leaders from the Philadelphia, Pennsylvania, area, moderator Lawrence N. Shulman, MD, FACP, FASCO, deputy director for clinical services at the Abramson Cancer Center of the University of Pennsylvania, highlighted the central quandary of the US healthcare system:

“In cancer, our outcomes in this country are not as good as they are in other places,” he said, opening the September 19, 2019, of the Institute of Value-Based Medicine®, an initiative of The American Journal of Managed Care^®. “In spite of the fact that we’re spending huge amounts of money, somehow our patients aren’t

doing quite as well, and I think that is a very disturbing finding.”

Getting better outcomes—without more spending—will mean doing things differently. To further discuss this, Shulman turned to Richard Snyder, MD, executive vice president of Facilitated Health Networks and chief medical officer of Independence Blue Cross; and Justin E. Bekelman, MD, director of the Penn Center for

Cancer Care Innovation at the Abramson Cancer Center.

Payer Perspectives on Advancing Value-Based Care Agreements

Focusing on the high healthcare prices in Philadelphia and other regional metropolitan areas, Snyder discussed the impact these costs have in keeping and attracting business. “For many P&Ls [Profit and Loss statements], the second line item behind labor is healthcare cost,” said Snyder. Currently, US healthcare spending per capita accounts for approximately 18% of the nation’s gross domestic product, which Snyder says is dangerously close to 20%, and a line the country cannot cross.¹

For employers, the transition from fully insured to self-funded healthcare is an issue that arises as companies grow. Snyder stressed that when healthcare claims cause reinsurance costs to become more than a business can bear, funding for healthcare becomes derailed. When patients experience cost shifting and a lack of cost transparency, it can cause them to delay treatments and preventive care, even though this can lead to increased treatment costs in the future. The rise in co-pays and member out-ofpocket costs occurs with high-deductible plans. For many patients, Snyder said, high out-of-pocket costs and a lack of healthcare knowledge contribute to healthcare-related bankruptcy.

To address the public’s limited understanding of how the healthcare system works, quality information is vital to allow for more informed decisions to be made. Snyder emphasized the need to publish more information about the quality of care, although this process has been met with lawsuits from medical centers claiming defamation. “How many people ask their physician: How many cases do you treat and what are your outcomes? Patients are scared to do that; they’re fearful it will insult the physician, even when it is their life,” said Snyder.

Nevertheless, inviting patients to discuss treatment options for their conditions and providing them with ample information to make good decisions is a process that is expanding. In Pennsylvania, some hospitals are designated as Blue Distinction Centers, meaning they are recognized for their expertise in delivering specialty care.² Snyder says that these newer models can assist in ameliorating costly treatments by prioritizing the concept of value-based contracting. How patients experience care is a variable Snyder said is growing in importance. Heightened accountability toward physicians and medical centers is being achieved through tools such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey.³

In lowering costs and improving care, Snyder described the concept of “Engage, Enable, and Empower,” which are steps that can be used to shift the focus toward patients:

• ENGAGE focuses on the value-based contract and the total value of care, promoting the responsibility of the health system to work with physicians for at least 1 year to take better care of insured patients. These contracts promote value-based care through tools like HCAHPS, and quality targets that would promote a 50:50 share for surpassing them and a 50:50 loss when missed.

• ENABLE represents the process of gathering information and exchanging data for analytical processing. The expanded data exchange would include variables such as electronic health record extracts, claims, lab results, and Admit-Discharge-Transfer messages in their databases, while additionally including opportunity analyses for analytics-based monitoring and reporting.

• EMPOWER uses the obtained information to increase opportunities for the use of innovative services (eg, telehealth to manage postacute care and home care) in order to increase care delivery options for patients. Snyder describes this as the most powerful step.

“This concept of doing everything the way we’ve always done and getting a different outcome just doesn’t work, we’ve got to change the way we think, we’ve got to break the old mold and build anew if we ever hope to get out of the mess that we’ve found ourselves in this country,” said Snyder.

Advancing Cancer Care Innovation Through Value-Based Care

As he opened his section of discussion, Bekelman emphasized that, regardless of the discernible innovations in cancer care, it continues to be suboptimal. “I would argue that we are at a turning point in cancer care today. We’ve made major strides improving survival, quality of life, but cancer care remains a multispecialty, multisetting, fragmented specialty with huge administrative complexity,” he said. In the United States, Bekelman continued, suboptimal care is attributed to one-third of the $3 trillion spent on healthcare every year.

Providing an example of one patient who had an unsatisfactory experience, Bekelman described a myriad of contributing factors that led to this level of suboptimal care. As the patient was diagnosed with prostate cancer, he had to undergo more than 8 weeks of both chemotherapy and hormone therapy at the facility and, given the demands of his occupation as a truck driver, he had to limit his routes to those close to home.

Given that the local care provider for the patient was separate from the healthcare system in which Bekelman worked, it impaired the coordination of the patient’s care. Several urgent care visits, and a nearby emergency department (ED) visit, were attributed to complications from the hormone therapy, which interfered with the patient’s glucose and affected his diabetes. The stress placed on the patient and his family was “totally avoidable,” said Bekelman.

Improvement through heightened glucose management during hormone therapy, and evidence that now points to 5.5 weeks of treatment as equal in effectiveness to 8.5 weeks, proved to be invaluable for Bekelman. “This gentleman’s experience was formative for me. As we confront this turning point in cancer care today, we need to challenge where we are,” said Bekelman.

To confront suboptimal care, Bekelman suggested that the goal should be to aim for multispecialty cancer care that is accountable for the total cost. Bekelman provided 5 elements of risk sharing, bundled care, or effective capitation for cancer care to achieve this goal: (1) Providers need to work as a team; (2) Providers should be responsible for all care and total costs; (3) Providers should tie payment to quality and outcomes; (4) Adjust payment for risk; and (5) Price in lean healthcare in an appropriate margin for providers.

“Working as a team triggers a reorientation of how we work together,” said Bekelman. By collaborating as a team, as opposed to separate departments, Bekelman stresses that consistent expectations will be set for each specialized care physician. Furthermore, the incorporation of allied health professionals, nurses, and nonlicensed coordinators will heighten efficiency in the pursuit of value-based targets.

Once team-based care is in place, Bekelman highlights the need to partner with generalists to ensure that comprehensive care does not get overlooked. “If we think back to this gentleman with diabetes, in the world of silo care, he falls through the cracks. In the world of multispecialty accountable care for cancer—the ideal world—he’s taken care of,” said Bekelman. By essentially becoming the general contractor for patients with cancer, Bekelman says it allows providers to manage total costs. This process of risk sharing will achieve a sought-after care model for payers and patients, noted Bekelman.

Tying payments to quality and outcomes is an issue that Bekelman describes as both a challenge and an opportunity. Starting off with a limited set of measurements and expanding them was recommended in the discussion, with patient experience serving as the primary factor. Press Ganey, a healthcare performance analytics provider, was highlighted for increased use as this rating system would motivate physicians to improve care through details provided by patients.

Adjusting for risk is an additional challenge. Although most oncologists may be put off by bundled payments due to variations in the health of their assigned patients, Bekelman suggests incorporating this practice onto patients with diseases who do not need much risk adjustment, such as those with early-stage breast cancer. Bekelman concedes that this cannot be done instantly, even if he desired to, but in utilizing a staged approach, adjusting for risk will grow in healthcare.

For the last element, pricing in lean healthcare in appropriate margins can be achieved through increased provider knowledge of costs, indicates Bekelman. “We have to understand [costs] to understand: how does the ask from the payer side comport with how we make margin?” By understanding the costs at main hospitals and community-based practices, providers can assist in steering patients to cost-effective treatments.

Once these costs are known, it delineates value of care through pricing in the appropriate margin. “Those providers that get ahead of this and provide a true value equation to insurers or employers, those are the ones who end up being the market leader,” said Bekelman.

References

1. National Health Expenditure Data: historical. CMS website. cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. Updated December 11, 2018. Accessed September 27, 2019.

2. Blue Distinction Centers. Independence Blue Cross website. ibx.com/individuals/find_provider/blue_distinction.html. Accessed September 27, 2019.

Implementing Practice Transformation, Integrating Primary Care to Raise the Quality of Cancer Care

3. HCAHPS: Patients’ Perspectives of Care Survey. cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQuality-Inits/HospitalHCAHPS.html. Updated December 21, 2017. Accessed September 27, 2019. As practices strive to offer patients the best care while also containing costs, it has become clear that following the old methods won’t cut it. As a result, practice transformation has become a norm for many practices looking to succeed under value-based care models, such as the Oncology Care Model (OCM).¹

For Jefferson Health, headquartered in Philadelphia, Pennsylvania, the process began a decade ago, when the health system decided to develop a multidisciplinary geriatric oncology evaluation center, Andrew E. Chapman, DO, FACP, chief of cancer services at Sidney Kimmel Cancer Center at Jefferson, said during the second half of The American Journal of Managed Care^®’s Institute for Value-Based Medicine® (IVBM) session held September 19, 2019, in Philadelphia.

The cancer center implemented a team-based model, bringing together social work, pharmacy, nutrition, and medical oncology. What leaders learned, Chapman explained, was that the group of patients accounting for the majority of cancer diagnoses, deaths, and survivors—those 65 years and older—are a significantly vulnerable population due to confounding factors, such as comorbidities and polypharmacy.

Faced with these facts plus a fragmented healthcare system, Jefferson Health officials stepped back to ask, “How can we think about how to address these cracks and think about this patient population in this fragmented system, and can we do something better?”

From there, the health system started down the path of practice transformation. The pace accelerated as the National Committee for Quality Assurance introduced its Patient-Centered Medical Home Model² and picked up even more with CMS’ introduction of the OCM.

As health system leaders considered what needed to be addressed during this process, Jefferson Health identified multiple aspects of care to be implemented, including team-based care, patient care management, and care coordination.

From there, Jefferson Health worked on building a system infrastructure that could withstand the changes needed, one that could facilitate engagement with providers by creating a culture in which they understood how interrelated they are to the healthcare delivery system. Leaders also offered assessments to providers by providing data and feedback.

“The Oncology Care Model for us has been this test tube for us to try to test really different opportunities in terms of building this infrastructure, sharing these data analytics, and trying to really evolve as a practice,” Chapman said.

Making Progress With Providers

Fast-forward to 2019 and Jefferson Health has laid out a series of goals:

• Develop and execute a strategy for addressing care needs across the continuum of care through navigation and supportive medicine.

• Execute a strategy to reduce cost and care variation. Demonstrate improvement in guiding patients to the appropriate site of care and creating meaningful care goals.

• Disseminate this data through a community strategy so that providers understand what is being measured and why each measure is important.

• Share this information with providers.

Throughout the year, Jefferson Health has worked toward several goals. The health system has addressed unnecessary care variation by creating a data operationalization strategy to identify the factors that drive clinical and cost outliers in practice. An oncology navigation team will focus on care coordination and outcomes and outreach, as well as implement a pathway system.

Jefferson Health has also worked on guiding patients to the appropriate site of care by looking at how to reduce avoidable emergency department (ED) use. Baseline data on patients visiting the ED who did not got admitted showed that just shy of 50% of those patients go the ED while the clinic is open.

“We saw this as a huge opportunity to say, ‘How can we leverage the triage algorithms that we built for all the different symptoms, and how can we leverage our same-day clinic where patients can be immediately plugged into when they call the practice?’” Chapman said.

The health system, in response, started a campaign to educate both providers and patients about the importance of calling a practice beforehand to ensure direction to the appropriate site of care.

Taking on a third goal, the health system opened up the Neu Center for Supportive Medicine & Cancer Survivorship, which this year has screened nearly 900 patients for distress and facilitated advanced care planning discussions early on between providers and their patients.

Looking ahead, Chapman outlined several challenges for the coming year, including scaling capabilities, implementing programs to manage high-risk or targeted populations, and engaging primary care and specialty practices.

A Focus on Primary Care

Integrating and engaging primary care in cancer care and survivorship has been of keen interest to other health systems, too.

During IVBM, Kelly Filchner, MSN, director of Fox Chase Cancer Center Partners, traced the cancer center’s steps to integrate primary care into oncology patient management.

“Primary care physicians believe they are an integral part of cancer care, but they need the tools to be part of that team,” she explained. For Fox Chase Cancer Center, this plays an especially important role in survivorship.

Realizing that many patients transitioning out of oncology care did not have a primary care provider (PCP), the cancer center created Fox Chase Cancer Center Care Connect. The team started by identifying and building relationships with PCPs in the area.

Fox Chase also set clear goals regarding the value it intended to get out of the program. For providers, the cancer center wanted to ensure effective access and communication, improve physician metrics, and enhance shared collaboration and support of a growing survivorship population. For the cancer center itself, goals included improving the transition of patient to survivor; providing an opportunity for screening, risk, and diagnostic services; and dispelling the notion that Fox Chase is limited to cancer treatment. “You can’t just create a program and then let it be on its own. You have to constantly be doing something; you have to constantly be

monitoring,” Filchner said.

Currently, the program comprises 33 PCP practices representing 50 family medicine or internal medicine physicians and 22 midlevel practitioners; it also includes 3 obstetricians and gynecologists, Filchner noted. To date, the program has referred 300 patients who did not have a PCP.

References

1. Oncology Care Model. CMS website. innovation.cms.gov/initiatives/oncology-care/. Updated September 11, 2019. Accessed October 2, 2019.

2. Patient-Centered Medical Home (PCMH). National Committee for Quality Assurance website. ncqa.org/programs/health-care-providers-practices/patient-centered-medical-home-pcmh/. Accessed October 2, 2019.