Challenges With Transforming Into an Oncology Medical Home
“We have come a long way—3 years since the concept of an Oncology Medical Home (OMH) was generated,” said Daniel McKellar, MD, who chairs the Commission on Cancer (CoC), a consortium of 56 diverse professional organizations (including clinical registry organizations and patient advocacy groups) that sets and monitors quality standards to ensure improved outcomes and quality of life for cancer patients. Speaking at the Payer Exchange Summit on Oncology Payment Reform, hosted by the Community Oncology Alliance (COA) on October 27, 2015, in Tysons Corner, Virginia, McKellar insisted on meaningful feedback from the community to ensure adequate transformation of practices into a medical home.
McKellar created a case for why CoC is the right body for OMH accreditation. “CoC has significant experience accrediting cancer programs. We are leaders in quality metric development and implementation, and we have a significant infrastructure in place,” he said.
McKellar informed the audience that the OMH work group, which includes participation by COA, the National Comprehensive Cancer Network, and the COME HOME group, has developed various standards and quality measures. With 10 pilot surveys completed, a standards manual has been finalized, he said, adding, “So far, we have 10 Oncology Medical Homes accredited by CoC, and we have plans to open up accreditation to 20 to 30 practices in 2016.”
McKellar insisted that payers have to be a part of the conversation to ensure these standards and quality measures are meaningful to them, as well. The accreditation process, he said, includes surveyor teams consisting of medical oncologists, and collecting feedback and input from participants on the standards will be an ongoing process. “This will not only further refine the standards, but it will also help develop education programs that can be disseminated within the community,” McKellar said.
In an article published in Evidence-Based Oncology
earlier this year, McKellar described the various domains that CoC uses to measure compliance (Figure
The process itself includes the following steps:
Practice submits application
Practice completes survey application record
Survey practices reviewed by surveyor on-site
Report submitted by surveyor staff
Performance report will be generated.
Clinics are expected to resolve any deficiencies within 12 months of receipt of the performance report. The duration of accreditation is 3 years.
McKellar said that CoC is providing education and support for the community through various means, including developing the standards manual, an OMH accreditation 101 seminar, webinars, and examples of best practices. “CoC is also training—but not promoting—consultants to assist practices in transforming into an OMH.”
“Accreditation does matter. It demonstrates that the practice believes in raising its standards of care for patients and their commitment to quality of care. It also improves patient satisfaction,” McKellar concluded.
In a subsequent panel discussion, McKellar was joined by representatives from several practices who have received their OMH accreditation. The panelists provided feedback on their experience with the program and the challenges they had to surmount to bring about the transformation.
“We have multiple sites of service, and wanting to provide the same level of care at all of those sites was a challenge. Trying to centralize things is a challenge,” shared Charles Bane, MD, Dayton Physicians Network in Ohio.
Pointing to the financial challenges associated with this massive change, Brian Borbeau, Oncology Hematology Care, Ohio, said that transformation has a price associated with it. “Transformation can prove expensive while we are adapting to it, but once we reach the other side, it’s easier,” he said.
Tammy Chambers of The Center for Cancer and Blood Disorders, acknowledged the support they received from COME HOME. “We had a grant to help us through the cost of transformation Also, Aetna and UnitedHealthcare helped us participate in the shared-savings program, and those savings were fed back into the practice to offset the increased costs we faced during the transformation.”
Insisting that the accreditation helped them tell their story, Chambers added that their clinic was practicing evidence-based quality care all along. She told the audience that the transformation, although a lot of work, eventually helps strengthen the practice. “Payers will eventually recognize the value of the accreditation,” she claimed.
When asked by Bo Gamble, director, Strategic Planning Initiatives, COA, what their advice would be for other practices who would want to follow the OMH route, panelists had the following responses:
Identify a physician surveyor
It will help payers notice you
The entire staff should be on board
Every new process needs a cultural or a mindset change, and this must be reinforced with both staff and patients.
1. McKellar D. Commission on cancer and the Oncology Medical Home. Am J Manag Care
Payment Reform Pilot Updates at the COA Payer Summit
An aging population, technological innovation, increased awareness resulting in earlier screening, and improved treatment regimens that have made cancer a chronic disease in some cases—all of these factors together have a significant impact on the growing cost of oncology care. In an attempt to curb this increasing financial burden on the US healthcare system, several payment reform pilots are being evaluated by payers in collaboration with their clinical care partners. At the third Payer Summit hosted by the Community Oncology Alliance (COA), payers and providers took to the stage to provide a progress report and discuss challenges and lessons learned along the way.
The first case study was presented by Michael Kolodziej, MD, national medical director, Oncology Solutions, Aetna, and Russell Hoverman, MD, vice president, Quality Programs, Texas Oncology. They provided an update on the clinical pathways pilot program at Texas Oncology. Kolodziej said that he had played a significant role in developing the pathways program while he was still with US Oncology to evaluate its impact on cost of care. “We were successfully able to show that pathways can reduce cost while maintaining the quality of care,” he said. After joining Aetna, “We convinced Texas Oncology to let us try the pathway in the Medicare Advantage program (MA).” The Aetna Teacher Retirement System MA Innovent Oncology Program1
has yielded about $4180 savings per patient in the first year, Kolodziej said, with total savings of $765,000 among 183 members. “The second year savings are even better,” he added.
The pathways program is still a product in evolution, according to Hoverman. “When we tied income to pathways performance, we saw a tremendous improvement in performance,” he said. In his opinion, pathways and guidelines, tiered drug fee schedules, care management and patient support services, advance care planning, and payment structure all contribute toward bending the cost curve while helping deliver quality cancer care. Support tools such as “Clear Value Plus have tremendously improved data compliance, which, in turn, has improved pathway performance,” Hoverman told the audience.
Pointing out that being responsible for the total cost of care is a whole new arena, Hoverman thinks that hospital-generated data can be pooled with the data generated in smaller physician practices for improved progress. “The cost of drugs and cost of care means we have to change,” he said.
The next pilot program introduced was UnitedHealthcare’s episode payment program that was piloted at 5 medical groups, including Northwest Georgia Oncology Centers. Lee Newcomer, MD, MHA, senior vice president at UnitedHealthcare, explained that the episode model was rooted in rewarding performance and cutting back dependency on drug volume and sales. A gain-sharing model, the participating clinics registered all patients with breast, colon, and lung cancer and provided clinical data to the payer. A single-episode payment was made at the initial visit and drugs were reimbursed at the average sales price rate. All physician services continued to be reimbursed as fee-for-service (FFS). “Episode payments remained unchanged with drug changes,” Newcomer explained.
Measurement of annual performance found that the episode payment model resulted in tremendous cost savings. Newcomer then showed data, now been published in the Journal of Oncology Practice
showing that although the FFS cost for the 810 patients from the 5 practices was expected to be $98,121,388, the actual cost was $64,760,116; a huge saving of $33,361,272 in total medical costs. However, drug costs increased, said Newcomer, from $7,519,504, to $20,979,417 during the period of data collection between October 2009 and December 2012.
“The program has since expanded; Texas Oncology started in January. We now have a third wave of practices joining in, but we have frozen participation right now. Since the first wave of pilots was so successful, we need to see them duplicated before we move forward.”
“We are very encouraged by this project…that there are opportunities for savings,” said Newcomer. “No matter the approach, community oncologists have the opportunity to be rewarded for the value they bring.”
According to Scott Parker, executive director of Northwest Georgia Oncology Centers, the essential requirements of a successful reform pilot are a cohesive practice group, strong analytics capacity (either in-house or outsourced), strong reimbursement, a strong clinical manager, a strong treatment planning approval procedure, and active collaboration with customer service for patients. “From our standpoint, these key components—though obvious and simple in concept—are critical to develop an innovative payment model,” said Parker.
Another pilot program that was discussed was the COME HOME project that has been the brainchild of Barbara McAneny, MD, who leads New Mexico Oncology Hematology Consultants.
Steve D’Amato, BSPharm, BCOP, executive director of New England Cancer Specialists, shared the adaptation of the COME HOME project at his practice. “It transformed and positioned us for the future,” D’Amato said, adding that it required commitment, buy-in, and a lot of energy.
In his experience, COME HOME requires a triage system, and urgent care was a major component of it. It was key, he said. “Clinicians participating in the COME HOME program have their own set of pathways—that’s another essential component. At our clinic, we extended our daily clinic hours and began operating even on weekends—which was quite essential,” D’Amato said. He explained that although it did not directly impact cost, “patient satisfaction was through the roof.” This helped patients bypass visits to the emergency department (ED), which is an overall cost saving to the healthcare system, he said.
“COME HOME also positioned us for the Oncology Care Model (OCM),” the initiative proposed by CMS.3
“The infrastructure costs, though, are real to run this project. To transform the clinic into an OCM was huge, but COA and Barbara provided us with tremendous support,” D’Amato indicated.
McAneny said, “When we started COME HOME, we were only thinking of patients and doctors. Most of my patient population is poor. So the point was to keep them out of the ED and from being admitted to a hospital. The triage pathways that we created solidified what we were doing. We had to educate our patients and ask them to call us first rather than 911. This took a lot of educating our practice staff on how to handle these patients and them to teach patients to call us rather than ED.” She explained that the complexities of the healthcare system should be the least of a sick patient’s worries, so “we took care of navigating the healthcare conundrum for the patients.”
She acknowledged that working with COA and the Commission on Cancer for the accreditation worked very well for the project. “We have seen significant impact on total cost of care and reduced the number of days of hospitalization.” At the end of the day, McAneny wants to see a restructuring of payments “so physicians have the flexibility to do what they want to do while keeping patients happy with the quality of care they get.” EBO
1. Hoverman JR, Klein I, Harrison DW, et al. Opening the black box: the impact of an oncology management program consisting of level I pathways and an outbound nurse call system. J Oncol Pract
2. Newcomer LN, Gould B, Page RD, Donelan SA, Perkins M. Changing physician incentives for affordable, quality cancer care: results of an episode payment model. J Oncol Pract
3. Oncology Care Model. CMS website. https://innovation.cms.gov/initiatives/Oncology-Care/
. Updated November 13, 2015. Accessed November 17, 2015.