https://www.ajmc.com/journals/evidence-based-oncology/2018/april-2018/oncology-practice-transformation-helps-deliver-patientcentered-cancer-care-in-a-community-oncology-practice
Oncology Practice Transformation Helps Deliver Patient-Centered Cancer Care in a Community Oncology Practice

Kashyap Patel, MD; Maharshi Patel, MBA; Asutosh Gor, MD; Sashi Naidu, MD; Niyati Nathwani, MD; Radhee Kothadia, BS; Saheli Parekh; and Eric Singhi, MD

INTRODUCTION
The US healthcare system is in a state of crisis. Compared with other economically developed countries, the United States has been shown to be drastically overspending on healthcare while outcomes remain inferior. A 2013 report by the Institute of Medicine (IOM)—now The National Academies of Sciences, Engineering, and Medicine—described the US healthcare system as one that leads to “shorter lives, poorer outcomes.”1 While the United States leads in innovation for cancer therapies, the IOM report pointed out that the nation’s “increasingly chaotic and costly” cancer care system is in crisis and fails to deliver consistent care that is patient-centered, evidence-based, and coordinated.

Cancer care is among the fastest-growing segments of the US healthcare system, outpacing many other subspecialties. In the United States, total spending on cancer care has increased from $27 billion in 1990 to $124 billion in 2010, with spending projected to reach about $157 billion by 2020.2,3 Total costs of cancer care for the US population are predicted to increase across all phases of care: Cost drivers include technological innovation, rising costs of hospitalization, and a population-level increasing susceptibility to malignancy due to an aging demographic and increasing life span.4 Global spending on oncology and supportive care drugs reached $100 billion in 2014, with targeted therapy expenditures accounting for almost 50% of this amount.5 In the United States, oncology drug expenditures, excluding supportive care agents, increased by 18.0% from 2014 to 2015.5

Along with payers, employers, and the government, patients, caregivers, and family members shoulder an increasing share of these rising costs due to changes in benefit design, which now combine higher out-of-pocket costs with rising premiums and deductibles.Cancer treatment can have a substantial financial impact on patients and their families; in fact, financial toxicity has been cited as a contributing factor to adverse outcomes in patients with cancer.6-9

One possible way to reduce overall cost, improve patient experience, and improve outcomes is to shift the focus of healthcare delivery away from volume and toward value. Patient-centered cancer care (PCCC) holds the promise of addressing these issues. The Oncology Care Model (OCM), developed by CMS’ Center for Medicare & Medicaid Innovation (CMMI), is a leading pilot that has been in place for over a year and seeks to test the efficacy of PCCC for Medicare beneficiaries over the next 5 years.10,11

METHODS AND RESULTS
At Carolina Blood and Cancer Care Associates (CBCCA), we began exploring our practice’s journey from volume to value in 2013 by understanding the concept of patient-centered care and taking the steps necessary to acquire accreditation as a patient-centered specialty practice (PCSP) through the National Center for Quality Assurance (NCQA). Our path for NCQA accreditation primed us for the transition, as NCQA has many common denominators with OCM. Under the practice transformation requirements of expanded access leading to PCSP accreditation (a corresponding OCM requirement), we realized that expanded access would lower expenses, improve patient experience, and likely improve outcomes. We found that expanded access, including same-day appointments and weekend access, prevented unnecessary emergency department (ED) visits and hospitalizations.

As a part of the transition to PCSP, CBCCA started providing patients the convenience of same-day appointments and walk-in access. Our 2 clinic locations each have 2 slots per day reserved for walk-in patients. In addition to recruiting staff to accommodate additional patients, we created a triage process and pathways, and we trained both clinical and nonclinical staff to learn the relevance of these process changes. This initial investment is paying off in multiple ways. We have documented a significant increase in office visits resulting from phone triage (Figure 1). Initially, this seemed burdensome, as it required the allocation of additional resources. However, upon analysis of overall trends, we noticed a more than-50% increase in overall revenue from additional office visits over the 3-year period from 2014 to 2016 (Figure 2). For patients, same-day access and expanded access reduced the number of hours waiting in the ED, leading to both improved outcomes and quality of life (Figure 3), along with a reduced likelihood of after hours ED visits and hospitalizations (Figures 4-6). Additionally, patients were able to spend more time at home with their loved ones. Overall, patients and their caregivers received better quality of care. Patient satisfaction is being measured and data will be released later this year.

For payers, the increased quality of life for beneficiaries was coupled with a reduction in spending and a reduced likelihood of healthcare-associated conditions, as well as hospitalizations and visits to the emergency department.

DISCUSSION
OCM is the first major initiative by CMMI to pilot the transition from fee-for-service (FFS) toward value-based care. CMMI has been relatively flexible and accommodating of changes made to the program in response to stakeholder input. While OCM encourages oncologists to assume 2-sided risk, in which the practice is exposed to the possibility of both receiving shared savings and experiencing shared losses, the significant disparity between negative risk and upward reward is a barrier that has discouraged participating oncology practices from considering 2-sided risk. Additionally, fulfilling the data registry requirements in terms of data entry is both arduous and labor-intensive, and a high degree of technical expertise is required to do so.

Nevertheless, OCM is a first positive shift away from volume-based care to the value-driven path. Indeed, this transition into patient-centered care delivery will inevitably lead us down the path to fulfill the triple aim of better care, lower expenses, and improved patient experience. While Part B drug utilization is somewhat hard to regulate due to multiple factors, improving access to care— particularly, offering same-day access as well as slots to walk-ins—is low-hanging fruit, relatively easy to reach to help achieve the triple aim of healthcare reform.

CONCLUSIONS
Patient-centered care offers a definite option to address some of the challenges posed by ever-rising healthcare costs and deteriorating quality of care (Figure 7). The goal of value-based care in oncology is to improve the quality of care, while containing costs. Advanced APMs, such as the Medicare Shared Savings Program, 2-sided risk models, and OCM are examples of a shift away from the traditional volume-based FFS model. For the OCM, this objective targets Medicare beneficiaries through an episode-based payment model that financially incentivizes high-quality, coordinated care. In moving toward a value-based specialized care system, payers recognize and reward providers who proactively seek to improve the patient experience and health outcomes.

 
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