The Future of Oncology? COME HOME, the Oncology Medical Home

Oncology care is in the spotlight for health system reform. As the baby boomers age, we will see an increase in the number of cancer patients. Cancer patients are living longer, which requires more oncology visits, more treatment, and therefore more money. The problem is that healthcare already consumes 17% of gross domestic product.

Dr Donald Berwick inspired many of us to hunt for the Triple Aim: better health, better healthcare, and lower costs. My Innovation Center grant, COME HOME (Community Oncology MEdical HOME), was developed to meet the Triple Aim by working on the parts of the healthcare system that physicians can actually control—the site of service and the care we give.

It is becoming recognized by many, including MEDPAC, that there is a significant differential in the cost of care when paid for through the Hospital Outpatient Prospective Payment System rather than through the Physician Fee Schedule. Many articles have been published on the expenses incurred in emergency departments (EDs) and on the costs and consequences of hospitalizations. Patients hate to be in the hospital, and physicians hate to see patients get antibiotic- resistant infections, infectious diarrheas, bedsores, and all the other complications that can occur when patients are hospitalized.

COME HOME is built on the idea that if we can intervene, early and aggressively, in the sequelae of having cancer and its treatments, we can prevent complications that require hospitalization and ED visits. Patients stay healthier, stay home, and we save money with better care.

Over the years, it became increasingly apparent to me that keeping patients out of the hospital whenever possible made their lives better and my life easier. So we instituted policies and procedures at New Mexico Cancer Center to manage the side effects of cancer and its treatment. After we had been working on these policies long enough to generate data, I learned that we had saved the payers literally millions of dollars.

Health plans, including Medicare, have attempted to direct patients to lower-cost sites of service. Pilot projects have included nurse hotlines or navigators or care coordinators. The Congressional Budget Office has looked at the Centers for Medicare & Medicaid Services (CMS) pilots and concluded that inadequate savings have been achieved. My theory is that these systems don’t work because the person trying to coordinate care is not part of the practice that is managing the patient. When the phone nurse gets beyond her or his comfort zone, she or he sends the patient to the ED to avoid potential problems.

Replicating Success

At New Mexico Cancer Center, a physician- owned multi-disciplinary center, we instituted an integrated triage system where the nurses follow a written protocol and schedule patients accordingly. This requires same-day scheduling, patient education, and a team-based approach. In short, we created an oncology medical home, long before we knew to call it that. Our data show significant savings to the payers, but more expense to the practice, as many necessary services are not reimbursed. When the Center for Medicare and Medicaid Innovation offered an opportunity to apply for a grant that would allow us to demonstrate and expand our processes, I set up a company called Innovative Oncology Business Solutions, Inc (IOBS), to write the grant and manage the project. IOBS was awarded $19.8 million.

The award will test whether this process can be replicated in other practices across the country and can produce similar savings. We must demonstrate that the care we provide is at least as good as what is currently standard care (I expect it will be better), and that the model can eventually be sustainable. I have selected 6 additional practices across the country to participate.

Triage Pathways are the heart of the program. This provides a scripted response to patients who call with problems and is designed to result in the patient getting care at the right site of service immediately. Order sets for given problems are combined with same-day visits scheduled by the triage nurses according to the acuity of each patient’s problem.

For example, a caregiver brought an 86-year-old man with pancreatic cancer to our cancer center with hypotension, no fever, hypoxia, and incoherence. Within an hour, we had labs back, cultures drawn, a CT completed to rule out pulmonary emboli, and his first liter of fluid and first dose of antibiotics given. By the time the hospital had a bed available for him, he was alert, conversant, and had normal have E coli sepsis. Had he gone to theED, that process would have taken hours. Leaving an elderly man shocky for hours could result in kidney damage or cardiac damage, and usually requires an intensive care unit visit or a prolonged hospitalization. Our intervention resulted in the patient complaining the next morning about cold coffee, and a discharge a few days later. This is clearly better health, better healthcare, and lower costs.

Creating the Infrastructure

However, significant infrastructure is required for a clinic to be able to respond as we can. Practices were selected based on their ability to create that infrastructure, which in healthcare means caregivers. Because those salaries and services are not paid for by the usual fee schedule, the grant money must cover it.

Each practice is experienced in the use of an electronic health record (EHR). Acquiring data in a time frame rapid enough to change behaviors is key. Part of the money will be used to develop a software system to extract clinical data and pathway compliance from the EHRs and to combine that with Medicare claims data. The pathway compliance data will be on the lead physician’s dashboard weekly, giving him or her the ability to work with the physicians of the practice and stay on pathway. Physicians respond to data, and showing that other doctors can do a better job for their patients provides a very strong incentive to change behavior.

Patients enrolled into the process will be newly diagnosed Medicare patients with 7 cancer types. A physician-led team, supported by grant funds, will carefully monitor and educate patients. Patients developing problems will be cared for immediately, avoiding expensive complications. This process meets the concept of a Medical Home, and we hope to achieve NCQA certification.

We recognize that cancer patients will sometimes require hospitalization. When patients do require hospitalization, the admitting oncologist will be able to determine when that patient is stable enough to have therapy completed in the office. Extended hours will allow daily visits until the patient’s acute event has resolved. Just having the patient admitted directly to the oncologist, bypassing the ED and the hospitalists, will avoid significant expense. Transitions of care will be minimized. We will be monitoring for readmissions and hospital-acquired infections.

Rising Drug Costs

Hospitalizations and ED visits are only part of the increasing costs to the healthcare system for oncology. Drug costs are increasing to approximately 10% of healthcare costs, and cancer drugs account for a significant proportion of that cost. CMS and payers alike react to the increased costs with dismay and look to the delivery system for assistance. United Health Group and Aetna both have pilot projects designed to control drug costs. Some payers have considered moving chemotherapy to the pharmacy benefit instead of leaving it in the medical benefit, in the forlorn hope that pharmacy benefit managers can solve the problem. Another option Congress is considering is to decrease the payment from Average Sales price +6% to something lower in hopes that use of drugs will diminish. Payers are hoping that defining pathways (specific therapies for specific cancers) will curb costs, and if that doesn’t work, they hope strict prior authorization processes will decrease use.

If CMS decreases payment for drugs by either of the proposed mechanisms, the pharmacy inventory costs incurred by independent oncology practices will become overwhelming, and practices will not be in the business of chemotherapy administration. Unfortunately for CMS, the need for the chemotherapy will not diminish. The patients will just be referred to hospital-based infusion centers, and the price will increase. Both Avalere and McKesson data show higher costs for chemotherapy in hospital-based systems. In my practice Icalculated the true overhead costs of maintaining inventory control of chemotherapy, and it is significantly higher than the 6% CMS allots. My ability to continue providing infusion services for Medicare patients depends on my ability to cost shift to commercial payers, who are increasingly indisposed to allowing cost shifting from government programs to be factored into their reimbursement schedules.

Pathway development will have a limited effect on drug costs as well. In the practices of the Oncology Circle (a group of 30+ oncology practices that share data) the vast majority of physicians are following NCCN guidelines. Once the practices become adherent to the pathways, and the outliers are brought into compliance, all the available savings from pathways will have occurred. Similarly, utilization review and prior authorization will not decrease costs in a significant way in oncology.

The American Medical Association has calculated the increased costs of participating in prior authorizations as about $1742 per doctor per year. Yet my experience is that I have never been turned down by a prior authorization peer reviewer. If literature exists to support my choice of therapy off label, or if therapy is listed in the guidelines, insurers are very reluctant to incur the wrath of cancer patients by denying care.

The basic problem is that all of these strategies are nibbling around the edges of drug costs. I cannot control the costs, I must pay the price the manufacturer requires, and I must use the drugs. The nation has not shown the political will to take on PhRMA and truly address the problem of drug costs. They would prefer to aim at the easier target of the practicing physicians. But eliminating the low-cost provider of the services— physician fee schedule practices—will not solve the problem.

The COME HOME project will require pathways to be followed for both the diagnostic and therapeutic parts of what we do. The computerized data extraction will measure the compliance with the pathways on a nearly real-time basis. This will allow us to be certain that the standard of care is met. We do expect some savings from pathway adherence, but obviously the drug costs will continue.

Personalized medicine includes molecular diagnostics. These genetic tests are expensive and the field is rapidly evolving. Getting the appropriate markers at the appropriate time will provide better care by avoiding the use of ineffective therapy and focusing on targeted therapy where it is available. Our diagnostic pathways will include these markers, and we will work with a group of experts in the field to make sure our pathways are appropriate. We will include these data in our clinical and economic outcome results.

Conclusion

If the COME HOME hypothesis is correct, and community oncology practices do provide quality care at a lower cost, in a setting more convenient to patients, we will work to export this model to practices and payers. If we understand the costs that must be covered in the office to avoid costs elsewhere, the payment structure will have to change. Hopefully, at the end of the 3-year grant, we will know what is included in an oncology bundle and the cost. Then, we can truly be paid for value and achieve Dr Berwick’s Triple Aim.

Author Affiliation: New Mexico Oncology Hematology Consultants, Albuquerque, NM.

Funding Source: The project described was supported by Grant Number 1C1CM5330969-01-00, the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this article are solely the responsibility of the author and have not been approved by the Department of Health and Human Services, Centers for Medicare & Medicaid Services.

Author Disclosure: The author reports ownership and board membership of Innovative Oncology Business Solutions (IOBS), Inc. She also reports receiving grants from IOBS and has stock ownership in the New Mexico Cancer Center.

Authorship Information: Concept and design; drafting of the manuscript; obtaining funding; and administrative, technical, or logistic support.

Author correspondence to: Barbara L. McAneny, MD, CEO, New Mexico Oncology Hematology Consultants, 4901 Lang Avenue NE, Albuquerque, NM. E-mail: mcaneny@swcp.com.

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