Lessons From a Texas Oncology Practice Within an Integrated Network
In the era of value-based care, community oncology practices are challenged to develop the infrastructure for quality reporting practices. How can practices do this and stay independent?
For 19 oncology practices across 17 states, the solution comes from being part of a clinically integrated network (CIN). The Quality Cancer Care Alliance (QCCA), which began with conversations in 2014, formally became a CIN in February 2018.1
At Patient-Centered Oncology Care®
, the chief executive officer of a QCCA member practice, Barry Russo of the Center for Cancer and Blood Disorders in North Texas, described how this geographically diverse group of practices had come together around a common set of values, recognizing the need to work together to achieve the scale needed for CMS quality reporting programs.
The idea of a “super group,” Russo explained, would allow these practices to join forces for benchmarking, to share best practices, and to be served by committees covering education, data sharing, purchasing, research, quality, and value-based care.
“Each member is at a different phase of maturity in quality reporting,” he said, which pres- ents challenges but is also part of the point—for community oncology practices to survive, they must learn from others.
When members of the super group pull together data from across the network, “they are working to have the kind of data they need, and the business intelligence to foster a value-based environment,” said Russo.
One thing the QCCA collectively does is unravel contracts with electronic health record vendors that make it difficult or impossible for practices to get back their own data in a usable way for quality reporting purposes. “How do you not have access to your own clinical data? Believe it or not, there is a lot of this out there,” Russo said.
The QCCA also helps practices get both clinical data and claims data, which can inform a practice about a few different things. “In our practice, we noticed that patients with COPD [chronic obstructive pulmonary disease] had a lot of hospitalizations,” said Russo. In following up on these patients through the claims data, Russo and his colleagues realized “many of these people weren’t being seen by a pulmonologist.”
So, if these patients had breathing problems, “they just went to the emergency department [ED].”
Once the practice identified the 35% of their patients with COPD who were not seeing a pulmonologist, they made an effort to make referrals. The practice did the same for patients with congestive heart failure—the oncologists referred these patients to a cardiologist. “We wouldn’t have that information without the claims data,” Russo said.
From Early Lessons, To A Legal Framework
Russo said most practices have had little or no experience with value-based care. “We needed to do a lot of education on what that meant,” he said. Launching quality reporting initiatives can be “time-consuming and costly, especially if the practice hasn’t invested in that at all.”
In some cases, technical hurdles were the challenge, but in others, there were emotional decisions, such as moving the entire network to a single group purchasing organization to save money on drugs. “These were emotional decisions at the grassroots levels of the practice, and the hurdles are often huge,” he said.
It became clear that that the legal structure of the CIN was essential. And that meant agreeing to defined initiatives: clinical pathways, triage pathways, data integration, research, analytics, quality benchmarks, and value-based programs such as risk assessment and member match, the latter being a tool to account for members who are in the ED or the hospital.
For Russo’s Center for Cancer and Blood Disorders, using clinical pathways was not much of a leap, as the practice had implemented pathways 13 years ago. “In today’s world, it surprises me that there are practices that have not implemented pathways,” he said.
A key step, however, was moving triage out of the chemotherapy area and putting it in administration. The practice had to create incentives to keep patients out of the ED so that triage became a quality indicator and did not consist simply of answering the phone.
Data Integration and Pilots
So, what is the CIN accomplishing? Russo outlined several milestones:
- Most members use a common set of triage pathways; the rest have scheduled implementation.
- Clinical pathway compliance is mandatory across the CIN, as this is a key quality indicator.
- Today, 90% of the member practices contribute to data integration for benchmarking and enrollment in future clinical trials. This has allowed talks with a manufacturer for a value-based contract for a specific drug.
- Pilot programs are under way for an artificial intelligence risk assessment tool that will include special pricing for members of the CIN. Practices that are in the CIN and also enrolled in the Oncology Care Model (OCM) through CMS are taking part in a Member Match pilot that identifies attributed patients who show up in the ED.
The risk assessment tool builds predictive models, including information that may seem to have little to do with a patient’s medical history—such as tax data—but is proving to be 100% correct in predicting which patients will be readmitted and highly predictive (89%) on which ones will be diagnosed with depression. The QCCA is still evaluating vendors for analytic and actuarial support, to offer the predictive tools needed for practices to take on risk, Russo said.
He spoke of the need to deal directly with employers, who are increasingly cost-conscious. “Seventy percent of the market is self-funded,” he said. “Many of them have purchased second opinion programs specifically related to cancer ... but many programs have low utilization.” Once patients enter a facility certified by the National Cancer Institute, where costs are higher, “they never leave.” Employers are asking if there are ways through value-based care “where the cost structure may be a little more reasonable,” noted Russo. Through the CIN, the practices of QCCA get the volume of data across a large geographic landscape and the support of established vendors for analytic support, the ability to take on 2-sided risk in the OCM, and perhaps the ability to join with another CIN while publishing meaningful data.
He said the CIN offers his practice the chance to stay independent while still “getting bigger” from the standpoint of having services at scale. Sharing information means knowing right away when new drugs come out, what a payer’s policy is, or how a patient’s genomic fingerprint affects what kind of therapy they should have. The physician can have this information immediately.
The bottom line, Russo said, is that “all this stuff has to happen at the point of care.”
QCCA evolves to become the first national clinically integrated network in oncology [news release]. Puyallup, WA: PRNewswire; February 21, 2018. prnewswire.com/news-releases/qcca-evolves-to-become-the-first-national-clinically-integrated-network-in-oncology-300602217.html. Accessed January 14, 2019.
Using Clinical Pathways to Improve Quality of Care, Prepare for Value-Based Future
During a session at Patient-Centered Oncology Care®
panelists drew on their own experiences of utilization and innovation of clinical pathways and pushed back against criticisms about the systems.
Clinical pathways are not “cookie-cutter medicine,” said Robert Daly, MD, MBA, medical oncologist, Memorial Sloan Kettering Cancer Center, who explained that the idea behind pathways is not that they will cover all patients, but that they will be able to guide decision making for most of them. Daly added that many pathway vendors have different levels within the pathway that account for nuances and comorbidities, and this allows physicians to make alterations to the treatment plan.
“I don’t really see it as cookie-cutter medicine; I see it more as advancing quality of care by better understanding what is the best treatment for those patients at that particular point in time and understanding that not all patients will be able to go along those pathways,” he said.
According to Lawrence N. Shulman, MD, deputy director, clinical services, Abramson Cancer Center, University of Pennsylvania, clinical pathways have also been criticized as another unfunded mandate that creates more work for over-burdened faculty. But, he said, the faculty at the University of Pennsylvania Health System have embraced their clinical pathways, which members of the hospital system created themselves.
With the belief that the main goal of the clinical pathways process is to change the culture of healthcare delivery, the hospital system brought faculty members together to dig in to why they treat certain diseases the way they do. The faculty also reviewed recent literature.
Similarly, Levine Cancer Institute, part of Carolinas HealthCare System, also developed its own pathway system with input from the faculty. Meeting once a month, the faculty update the pathways and determine which practices are preferred and which are acceptable based on the parameters of the patient, explained Edward S. Kim, MD, chair, solid tumor oncology, Levine Cancer Institute.
An important aspect of the pathway system is that it’s nimble, Kim said. This allows for new drug and treatment information to be added quickly and seamlessly. He used the example of when there was a shortage of the chemotherapy etoposide. The faculty were able to quickly remove the drug from the pathway system so that a physician didn’t order it and then find out it was not available.
The University of Chicago Medicine uses Via Oncology’s commercial system, an acquired third-party vendor-implemented system, which lets physicians dip a toe into the water of pathways while also allowing for some customization, said Blase N. Polite, MD, MPP, associate director, Center for Clinical Cancer Genetics, assistant professor of medicine, University of Chicago.
All panelists agreed that the pathway systems brought attention to the heterogeneity of care happening among doctors and allowed for collaboration and consensus going forward. “I think what we’ve emphasized is, with growing networks, it’s unconscionable for us to put the University of Chicago brand in place in a suburb of Chicago, and then people come there and don’t get the same care” as in the city, said Polite. “It’s also a way of protecting and customizing your brand.”
Both Shulman and Kim pointed to their pathway systems as being empowerment tools for their healthcare system, particularly for physicians at community cancer centers. “At most of the community hospitals, our oncologists are general oncologists, and it’s hard for them to keep up in all the different diseases of the patients they treat, so the pathways have really been invaluable,” said Shulman.
The clinical pathways systems also allow community practices to offer precision medicine, said Kim. Within the Levine Cancer Institute’s clinical pathway system, there is an approved genomic test for solid tumors that allows any physician in the healthcare system to order the test.
In response to a question asking how to change physician culture from “all of us do this differently” to adherence to the pathways, Daly said that in an institution, it is essential to identify who the thought leaders are and get their buy-in. Once the leaders start using the pathway to improve care, it will disseminate, he said. If you rush the implementation without the buy-in, he warned, you risk the stability of the project.
Switching gears to alternative payment models (APMs), the panelists agreed that clinical pathways have the potential to prepare healthcare systems for a risk-bearing future.
“I’m a big fan of the value-based pathway concept,” said Polite. “Where pathways are right now, I think they’re in their infancy. But I do believe that they have the potential to be our answer to the drug utilization issue for all the APMs we’ve been discussing, because once you start incorporating value into it, you’re seeing that this is going to be the number-1 thing on the pathway because of what it does in terms of the total cost of care, efficacy, and toxicity, and you start driving decisions that way.”
He added that if CMS’ Center for Medicare & Medicaid Innovation wants healthcare systems to take on 2-sided risk, drugs need to be taken out of the model, and if drugs are taken out of the model, there needs to be an alternative: holding physicians accountable for utilization with pathways.