Using Reimbursement Models to Overcome Oncology Care Gaps

Joseph Alvarnas, MD: You’ve articulated how we can improve in terms of becoming more patient centered in our approach and maybe even ways that we can measure it. Gaps still persist, and one of the complaints that I’ve heard from patients is that it seems like people don’t talk to each other. How can we improve intra- and inter-site coordination of care and address those kinds of gaps? Because it seems that things like unnecessary admissions, readmissions, and ER visits are sometimes the by-product of people not really speaking to each other. Bhuvana, I’ll start with you. How can we improve these coordination gaps, and maybe how can we change reimbursement models to ensure that these gaps get filled?

Bhuvana Sagar, MD: Great question. This is something that I care about a lot. Our patient-centered medical home that we put in place addresses just that. We try to have shared decision making to start with: making sure that the patient and the family are educated about their diagnosis, the treatment that they’re on, or the potential side effects that they’re going to expect or experience, and making sure that their symptoms are managed adequately—something as simple as pain management. A lot of times, maybe physicians forget to write the prescription, or they are not able to fill the prescription, and patients end up in the emergency room. We try to incentivize physician groups to do exactly that and have possibly a nurse navigator role in the practice.

We’ve had a single point of contact at Cigna to try to reach out to that nurse navigator to facilitate that discussion—to try to give them a daily census report of patients of that particular practice admitted in the hospital. Because a lot of times, they may not be admitted to that particular hospital the physician is going to and maybe get admitted somewhere else, and they may not be familiar with what’s going on. So, this way, we try to have someone from the provider’s office reach out to the patient and schedule an appointment, hopefully within a week or so, so they don’t get readmitted to the hospital.

We tried to put a lot of these measures in place to try to address these gaps in care. We also have a robust oncology case management program, where the case managers also try to reach out to the physician’s office and let them know that their patient is admitted, or if they need a pain medication, or that they’re talking to the patient. They also try to work through and sometimes help them with approvals. So we’ve tried to look at the patient as a whole and try to assist where possible to break down those barriers as much as possible.

Joseph Alvarnas, MD: How have incentives aligned to help promote that kind of care coordination?

Bhuvana Sagar, MD: Our model pays a care coordination fee to try to encourage these kinds of activities, and some practices are actively engaged in them—the physician group is engaged. It’s more of a team-based care, and the practices that have put in a team to do all these activities have actually done better than practices that have not done those functions or put a team in place.

Joseph Alvarnas, MD: Better in what way?

Bhuvana Sagar, MD: They’re able to engage the patient, educate them, and they’re able to keep patients out of the hospital as much as possible. We also try to encourage having 24/7 access, making sure that maybe there’s somebody else who’s taking the call. They have access to the EMR, so they’re aware of what treatment the patient is getting and they’re able to address the side effects. They document that the patient called. These are things that we’re asking them to do. Then the doctor—when they come in the next morning—has a message waiting for them to let them know this is what happened. We also encourage trying to have after-hours care. If they have nausea and vomiting, we try to get them in and hydrate them. When they do things like that, they seem like they’re able to avoid unnecessary hospitalization.

Joseph Alvarnas, MD: I think one of the common laments that I hear from oncologists in our network is “Well, we tell them to do that. We even give them wristbands with our phone number on them, but they still don’t call us. They still go to the ER.” So, it’s a constant effort. It doesn’t mean that we’re going to fix everything overnight, but it means that we’ve got a system in place to try to capture those patients to prevent avoidable care. And for patients who do end up in the emergency room or in the hospital, we have real-time admission, discharge, transfer, and ER data that let the physician know the patient is there.

But many of the elements that you describe are part of the CMMI oncology care model, where providers have to have 24/7 access to an EMR. I think that’s the way we avoid some of the confusion that exists. But physicians have to access it, and patients have to call to make that work. But I think more than anything else, we really have to fundamentally understand and transform how cancer care is delivered today. It’s becoming increasingly complex, and even most cancer patients still have their diabetes, and their heart failure, and their other comorbidities. So, communication is critical, and yet our communication technologies—while they may be better today—are they any better used than they’ve historically been?

I think there are lots of opportunities, but all of that requires time and energy and skill sets that most practices, at least community-based practices, don’t have. I think the notion of paying that care management fee, which is part and parcel of the OCM and what you’ve been doing since 2012, helps fund some of those things that are integral to transferring how cancer care is delivered, and yet we’ve never recognized it before. A lot of cancer care is the social workers, financial planners, and pharmacists who aren’t reimbursed today. So, I think we need to fundamentally reshape the incentives that exist and the payments that exist to help practices redefine how they deliver care.