Benchmarks for Measuring the Success of a Medical Home in Oncology
By Robert “Bo” Gamble and Mary Kruczynski
Mr Gamble is Director of Strategic Practice Initiatives
Ms Kruczynski is Director of Policy Analysis, Community Oncology Alliance, Washington, DC.
As we move forward in the scheme of healthcare reform, we are being directed toward an integrated care model, one with high quality and economic efficiency. Recently, a model known as an accountable care organization (ACO) was introduced by the US Department of Health and Human Services in the form of a proposed rule open for public comment. Although the final rule has not yet been released, the various submitted commentaries, at least as far as cancer care is concerned, were not very supportive of the model.
When we incorporate a diagnosis of cancer into the ACO model, however, we struggle to find the perfect fit. In an effort to conform to the newly outlined standards of quality and efficiency, The Community Oncology Alliance is leaning toward a more precise model that is better able to address the many services needed by patients with cancer. That model is known as the patient-centered medical home (PCMH) in general, and as translated into cancer care, patient-centered oncology medical home.
Cancer care is not well understood in the United States. One would think that because cancer ranks third in the US total healthcare expenses,1 it would get more mention in healthcare reform and accountable care proposals.
A proposed rule by the Centers for Medicare & Medicaid Services for ACOs mentions “quality” 817 times, “standard” 208 times, and “cancer” only 8 times (5 of which refer to screening measures vs actual cancer care).2 The National Committee for Quality Assurance’s (NCQA) outline for the PCMH mentions “quality” 62 times, “standard” 107 times, and “cancer” only twice.3
It is perplexing and indeed ironic that cancer is not understood, particularly in the context of cancer care as a medical home. Yet, most patients with cancer would refer to their community cancer center as their “medical home” and often their actual “home,” with “home” being a place of intense nurturing, support, care, love, and encouragement. Yet, to date, there is not an organized recognition entity that promotes and supports quality, patientcentric cancer care with applicable benchmarks.
The medical home model has merit, in that it has demonstrated improved efficiency, lower costs, and overall patient satisfaction.4 The incentives within this model also promote positive entrepreneurial competition, notably within an entire industry. ACOs, however, tend to create competition among themselves, which has diminishing marginal return. The medical home model appears to be more sustainable and more applicable not only for the medical community, but also for the diverse specialties within that community.
Successful Components of the Medical Home Model in Oncology
To be successful for all stakeholders, the medical home requires several qualities.
Collaboration. According to the NCQA’s white paper, 7676 clinicians and 1506 practices have achieved recognition as a PCMH, mostly through hard work and perseverance.5 The goal is to remain self-assured that this model is right for patients and for practices alike. What is needed now is recognition of this significant achievement. Most recognition models are either provider-driven with hopes that payers will follow, or payer-driven with hopes that providers will follow.
The oncology community is developing a medical home model that includes representation of the major stakeholders. The oncology-specific PCMH is steered by patients, oncologists, oncology practice administrators, payers, patient advocate groups, oncology support organizations, and other value-added partners. “Quality” has been defined by some people as “when you get what you thought you bought.” Each of these entities has its own definition of “get,” and that perspective of the deliverable needs to be considered and measured, if there is going to be a comprehensive approach to establishing and nurturing a medical home.
Easy implementation. The prevailing theme of oncology practices, and those who are supporting and encouraging these teams of passionate mission- minded caregivers, is “please, not another project.” Oncology practices are busy trying to keep quality patient care a priority, while trying to implement physician quality-reporting initiatives, e-prescribing, and meaningful use, and simultaneously lobbying for legislative support for cancer care, maintaining staff and physician morale, and hundreds of other toppriority issues.
Oncology practices will need assistance with implementing the policies, procedures, and workflow changes to achieve any type of recognition program. However, these tools and techniques need to be balanced to the point of promoting ownership and action, while easing the administrative burden of yet another major project.
Benchmarked quality measures.
The largest obstacle and one of the most critical components to a successful program will be the standardized, comprehensive, and automated submission of key quality measures. Many of the current quality programs require manual chart abstractions or consist of subjective questions that are not measurable (eg, yes/no answers).
Quality measures need to include ratio-oriented and well-defined numer ators and denominators; automation through systematic data capture techniques from valued electronic medical records (EMRs) or middleware vendors; and allowances so that practices can readily compare themselves to their peers.
Physicians and practice administrators will need to encourage their EMR vendors and group purchasing vendors to automate the reporting and submission of quality measures to a common data repository. This may also require database engineers to create discrete data dictionaries, where they currently do not exist.
Standardized patient satisfaction measures.
Most oncology practices gather patient satisfaction information on an ongoing basis, or they have done so in the past. The typical textual results include, “My physician walks on water”; “You guys are great—keep up the great work”; “So thankful to have such a team”; “Your kindness makes my day”; “Perfect—do not change a thing.” However, if we standardized the questions with a numeric scale, a consistent score of 95% may pale in comparison to benchmarked scores of ≥99%.
The benchmarking repository should also include submitted patient satisfaction scores. This survey needs to be simple, easily gathered at strategic points during the patient’s treatment, quantitative, and reflective of how a patient perceives quality.
Value. All these benchmarks must be structured and wrapped so that each group of stakeholders receives perceived value. The barometer of achievement needs to be high enough to allow for a real sense of accomplishment. Payers need to understand and support the significance of the effort and be willing to support the value financially.
The practice team should note the differences in the process through perceived increased efficiency and collaborative teamwork within all disciplines of care. Most important, patients and their families need to perceive and receive greater value through higher patient satisfaction.
Quality, Value, and Efficiency in Cancer Care
We are in a season of transition in the cancer care delivery system. Patients, payers, other providers, and government entities are campaigning and demanding quality, value, and increased efficiency. All these expectations will best be met through a model that encourages, promotes, and en – dorses ongoing achievement of these attributes. Although most oncology practices are meeting these expectations, a lack of understanding and clarity remains regarding how well these expectations are being achieved. Benchmarking key ratios of consistent quality, value, and efficiency will go far to bridge the gap between the expected, perceived, and actual quality achieved.
Benchmarking key ratios of consistent quality, value, and efficiency will go far to bridge the gap between the expected, perceived, and actual quality achieved. The biggest challenge is shifting the mindset of the entire cancer community toward a new emphasis on tools, processes, and measurements that promote and validate why cancer care in the United States is the best. Only then will we get what we thought we bought.
- Stanton MW. The High Concentration of US Health Care Expenditures. June 2006. Rockville, MD: Agency for Healthcare Research and Quality. Research in Action; Issue 19. AHRQ Pub. No. 06-0060. www.ahrq. gov/research/ria19/expendria.htm. Accessed August 1, 2011.
- Centers for Medicare & Medicaid Services, Medicare Shared Savings Program: Accountable Care Organ izations. March 24, 2011. CMS-1345-P, RIN 0938- AQ22. www.ftc.gov/opp/aco/cms-proposedrule.PDF. Accessed August 1, 2011.
- Standards and Guidelines for NCQA’s Patient- Centered Medical Home 2011. Washington, DC: National Committee for Quality Assurance. March 28, 2011.
- Grumbach K, Grundy P. Outcomes of implementing patient-centered medical home interventions: a review of the evidence from prospective evaluation studies in the United States. Washington, DC: Patient- Centered Primary Care Collaborative; November 16, 2010. www.pcpcc.net/files/evidence_outcomes_in_ pcmh.pdf. Accessed August 1, 2011.
- National Committee for Quality Assurance. NCQA’s Patient-Centered Medical Home 2011 overview white paper. January 31, 2011. www.ncqa. org/LinkClick.aspx?fileticket=l_KicggGGsQ%3d&tab id=1302&mid=5343&forcedownload=true. Accessed August 1, 2011.