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Community Practices Continue to Struggle With ED Use, Risk Stratification in OCM


While practice transformation is vital, community-based clinics continue to struggle with emergency department (ED) use, hospitalization, and risk stratification as they identify ways to reduce unnecessary expenditures within their Oncology Care Model (OCM) practice.

At the Community Oncology Alliance (COA) Payer Exchange Summit in Tyson’s Corner, Virginia, October 29-30, a small group practice and a mid-sized practice shared their experiences and learnings from the first 2 years of being in the Oncology Care Model (OCM) and provided the moderator from CMS feedback in the form of struggles and missed opportunities in the model as it currently functions.

Ellen Lukens, division director, specialty payment models, CMS, facilitated the conversation between Kashyap Patel, MD, CEO, Carolina Blood and Cancer Care, and Barry Russo, CEO, The Center for Cancer and Blood Disorders.

Explaining the objective of the panel, Lukens said that the audience can hope to draw perspectives from payer and provider learnings over the past two-and-a-half years of being in the OCM and where the future lies for this model. She hoped that the conversation would provide adequate guidance for oncology practices and health insurance plans who haven’t participated in the OCM yet.

“OCM was a brave effort from all of us, and it’s much bigger than what any of us anticipated at launch [of the program],” Lukens said.

Considering the complexity of cancer care, “we need a model that can manage [this complex disease] and is responsive for this level of care,” she said. Emphasizing the need for partnership among stakeholders, Lukens said that CMS continues to receive feedback on OCM from COA, the American Medical Association, and the Association of Community Cancer Centers, among other, “which has been tremendously valuable to the [Center for Medicare & Medicaid Innovation], and it helps improve the model.”

Anecdotal evidence has suggested that practices have performed well with care transformation, access, and communication, she said. “While 25% of participating practices achieved performance-based payment [PBP] in performance period 1, 40% did so in performance period 2, which is impressive,” Lukens told the audience. “Additionally, 75% of practices beat their benchmark in performance period 2—85% if we minus the care management fee.”

These are internal analyses, and independent evaluation results for the second performance period are expected by year end.

“We are open to suggestions at the two-and-a-half-year mark to improve the model,” Lukens said.

She then invited Patel to share his practice’s experience with OCM, who explained his clinic’s motivation to initiate practice transformation. “We started this process in 2013 for accreditation as a patient-centered specialty practice,” following advice from their payer partner, commercial Blue Cross Blue Shield of North Carolina (BCBSNC). The process stemmed from a threat that the clinic faced as a result of 2 big healthcare systems that were buying up practices in the surrounding area.

The transformation process required changes at multiple levels, including same-day appointments, walk-in access, and an upfront triage process to appropriately direct patients. But the most vital part of the process, in addition to adding to the practices’ head count, was employee buy-in, Patel emphasized.

“We brought in external stakeholders to speak to our employees on why we should bring about this change,” he said, which was followed by their initiating a pilot model with BCBSNC, before participating in OCM.

They identified emergency department (ED) visits and hospitalizations as the biggest challenges in their patient population, especially because of the rural population that their practice served, and educated their patients to call the clinic first in case of an emergency. “We added slots to our daily and weekend schedules to be able to see patients the same day.”

Since a lot of their patients were Medicaid-assisted, the practice looked at external sources of funding and raised about $1.6 million from foundation and agency grants “which was our second patient-centered move,” Patel said.

Additionally, Patel’s practice moved 100% of its patients to biosimilar filgrastim instead of the reference product, which led to additional cost savings.

“Patient triage, same day visits, and the use of biosimilars together had a big impact,” Patel said.

Additionally, to address the challenge of after-hours care, the clinic partnered with a local urgent care center, which added a second tier of support for patients who did not have life-threatening emergency.

However, the rural location of the practice remains a challenge, Patel said. Their analysis of high utilizers has identified a patient stereotype: most are Medicare-only, they live alone, and typically lack access to transportation.

Patel recommended that social complexities of patients should be included as a risk factor in the model.

Russo’s practice has had experience with several value-based care models for almost a decade prior to entering into the OCM pilot, including the COME HOME model and Aetna’s value-based care program. He listed similar practice transformation efforts as Patel’s clinic, including after-hours and weekend care and a centralized triage pathway system in addition to a lot of support services, including on-site dieticians, massage therapy, acupuncture, and navigators for educating patients. “This support team is vital,” he said.

But how do you pay for these supportive care services? While the monthly enhanced oncology services payments help fund these services, “we have reached out to outside foundations to receive financial support related to services that we do not charge for,” Russo said.

He also described some new programs that their practice implemented: a prehab program aimed at reducing falls in patients who are at a higher risk of falling after discharge. “It’s also had an impact on keeping patients on therapy after discharge,” he said.

One of their biggest challenges include the rural location of their practice. “We have made some dents in ED utilization, especially in some more urban areas, but our problem is that the ED is the rural population’s primary care provider,” he said, adding that they continue to struggle with this issue despite consistent patient education against visiting the ED.

To better equip their practice for risk stratification—another one of their ongoing challenges—The Center for Cancer and Blood Disorders has partnered with an artificial intelligence system that has 7 vectors, including depression, pain, risk for ED admission, risk for readmission, risk for 30-day mortality, and risk for 60-day morbidity, to recognize in a succinct way where the risk for patients in our practice lies. “This tool has made a big difference,” he said.

Finally, Russo pointed out that the lack of aligned incentives creates significant barriers for their cost-saving efforts.

In closing, Russo said, “We need all hands on deck for the success of this transformation—everyone from the front desk to the coders to the nurses. They all have to understand that this affects everyone’s day-to-day activities as well as financial well-being.”

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