Coverage of updates in value from Patient-Centered Oncology Care, November 16-17, 2017.
Moving away from a fee-for-service (FFS) reimbursement model to one that rewards value is no small undertaking for a busy practice. As the second day of Patient-Centered Oncology Care® opened on November 17, 2017, moderator Margaret O’Grady, RN, MSN, OCN, FAAMA, administrative director of the Oncology Service Line at Abington Memorial Hospital, Jefferson Health System, said it’s important to see the best practice methodologies.
In cancer care, that means understanding how practices are adapting to the Oncology Care Model (OCM), which is now in the second year of its 5-year run under the Center for Medicare and Medicaid Innovation.1 Lalan Wilfong, MD, medical director for quality programs at Texas Oncology, shared how adapting to the OCM caused Texas Oncology to dig deeper into what it did well, where it could improve, and where variation and excess staffing had crept in, given that the 420-physician practice had grown through acquisitions.
Wilfong outlined the OCM basics: the model operates in 6-month episodes, which can be repeated, with Medicare paying a services fee for qualifying patients as well as shared savings. Wilfong went through the required OCM elements:
When Texas Oncology first signed on for OCM, Wilfong said some responded, “What are you doing to me?” But others embraced it.
“What this forced us to do, for the very first time in our practice, it forced us to sit down and think about how we take care of our patients. We always thought we did a good job,” he said. The practice was growing, but oncology was changing so quickly. “What we never really thought through was, ‘Are we doing this well? Are we taking care of our patients well?’”
The number of OCM requirements forces the practice physicians to meet frequently to make sure they are meeting them, a process that has led to many changes that have helped patients, Wilfong said, offering several examples:
24/7 access. Texas Oncology’s physicians always took calls, but what did this requirement really mean? How did it correlate with reducing hospital admission and emergency department (ED) visits? The practice gained access to its CMS data feed to see which patients were ending up in the hospital, and followed that up with 2 things: it set a goal of reducing hospital admissions by 5%, and it said nurses could not refer patients to the ED without a physician’s order. “We hold our physicians accountable for their hospitalization rates. We share that widely in our organization,” Wilfong said.
“Most physicians are fairly anal-retentive people. They were used to being the A+ student in their classes,” he said. “When I give them a score card that shows that they’re red, not green, they don’t tend to like that very much.”
Texas Oncology also redeployed nursing staff to return calls from high-risk patients within 30 minutes, and it set aside appointment slots at each site that can only be used for urgent care—and these are consistently 90% filled.
Data for quality improvement. Gaining access to CMS data showed it made more sense for nurses to contact patients on day 3 of chemotherapy instead of day 2, which is when steroids were still having an effect. “We’re working on a high-risk identification protocol with increasing clinic visits and increasing proactive nursing phone calls,” Wilfong said.
The practice is also using data to optimize its antiemetics protocol for chemotherapy-induced vomiting, which calls on pharmacists to adjust the antiemetics based on the risk of each regimen. In a pilot of this effort, only 2 of 300 patients had a nausea grade of 5 or more on the Likert scale of 1-10.
Improving end-of-life care. The OCM process revealed a need for major improvements. “It surprised me, when we looked at our baseline numbers, how poorly our practice was doing at end-of-life (EOL) care,” Wilfong said. The doctors thought they were doing well, but the metrics showed something else: a need for better conversations, fewer hospitalizations near the end of life, and less chemotherapy.
It was a big challenge. “It’s hard to tell a physician who’s been practicing for 20 years that they [are failing] at end-of-life care,” Wilfong said. “They don’t like to hear it, and everybody kind of knows it. All the nurses talk about it behind their backs.”
Identifying those physicians who excel at EOL conversations and arranging for them to mentor those who need improvement is hard, and a work in progress. “I would love to tell you we have this fixed, but we don’t. But we are improving.”
Texas Oncology is using a program, My Choices My Wishes, to help physicians talk to patients, and building a culture of shared decision making. It’s producing results: a high percentage of those who go through the program complete an advanced directive. Among patients with an advanced directive, 76% die in hospice, with a median length of stay of 21 days compared with those who went through the program who did not do advanced directives, a group in which 61% died in hospice and had an average length of stay of 12.5 days.
Care plans along national guidelines. The compensation changes under OCM took Texas Oncology from 83% compliance with clinical pathways to 90%, a level that Wilfong says “is a perfect number to me.”
When physicians want to treat patients off a pathway, their decision requires medical review, a step that dramatically controls drug spending. “What I tell doctors all the time is that if you’re doing something, you should be able to stand up in a group of your peers and at least half of them agree with you. And if you can’t convince at least [half of] the people that what you’re doing is right, then you probably shouldn’t be doing it in the first place,” he said.
OCM raises the specter of taking on the taboo topic in oncology care. “Drug margins are a revenue source for oncology practices, and we’ve got to start talking about this if we’re ever going to be able to get a handle on our drug spend,” Wilfong said.
When practices have some patients in FFS and others in value-based reimbursement programs, it gets complicated administratively but ethically, too. “This is something...we have to get a handle on in oncology practices in order to be able to succeed in value-based programs in the future,” he said.REFERENCE
1. Oncology Care Model Fact Sheet. CMS website. cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-06-29.html. Published June 29, 2016. Accessed January 7, 2018.