The First NCQA-Recognized Medical Home in Oncology
The patient-centered medical home (PCMH) model of care has proved successful in overcoming some of the fragmentation of primary care. Dr Sprandio and his colleagues have now demonstrated the value of applying the principles of the medical home to cancer care, with particular implications for oncologists and for payers and unique reimbursement dilemmas.
Q: Your practice is the first oncology medical home to be recognized by the National Committee for Quality Assurance?
Dr Sprandio: Our hematology/oncology practice is the first, and still the only, cancer center in the country to have gained recognition from the National Committee for Quality Assurance (NCQA) as a Level 3 PCMH. We obtained that recognition in April 2010 after several years of preparations. In 2005, we began to restructure our processes of care. The idea of applying for the NCQA-PCMH recognition evolved in late 2009, after realizing that our reengineered processes met the majority of the criteria for Level 3 recognition.
The NCQA is now trying to determine the recognition process for other subspecialty practices, possibly developing criteria for medical home neighbor recognition. They will likely open up that process to other practices within the next 18 to 24 months. For a practice to be recognized as a medical home, it must currently meet 13 essential NCQA standards of patient-centric care, which our practice has surpassed. When we applied there were only 9 criteria, and the additional 4 are extensions of some of those 9.
Although other cancer programs and practices are now using the term “medical home,” they have not yet attained an officially recognized medical home status. They are working toward that goal, in terms of disease management and utilization outcomes, to meet the criteria for an oncology PCMH designation.
Q: What was the impetus for launching your oncology medical home?
Dr Sprandio: I founded our practice 23 years ago; we now have 9 physicians and more than 6000 active patients. We are in a very competitive environment in the Philadelphia suburbs. Our culture and belief have been, from the outset, to provide the best care and the highest level of service possible. To do that, we believe it is necessary to measure our performance on a consistent basis, to gain objective data, and to fix what needs fixing. This constant cycle of process improvement is also an NCQA requirement for a medical home. We developed this oncology medical home model because it was the right thing to do for patients: we also thought it would give us an advantage in a competitive marketplace.
The article I published last December (Sprandio JD. Community Oncol. 2010;7:565-572) has helped to spread the word that this model may have real value. There is a growing understanding about the value of this model for oncology. Community oncology practice, as well as health systems that employ oncologists, are interested in differentiating themselves in their market by potentially following our example and using our toolkit; they are engaging us to help them transform their practices to an oncology medical home. We have a Medicaid HMO contract that has been working very well for about 1 year and are currently in negotiations with our larger payers.
Q: What are some of the characteristics of the medical home in oncology?
Dr Sprandio: Studies have shown that the medical home is a wonderful model to enhance primary care delivery. It coordinates and reduces the fragmentation that plagues medical care today. And when this model is applied to an older, or more vulnerable, patient population with comorbidities, the potential benefits are multiplied. In cancer care, for example, because care is so expensive and the patient population is very vulnerable, better coordination in care delivery can lead to positive outcomes and fewer hospitalizations.
The medical home was initially proposed by pediatricians in 1967 for children with severe, chronic medical conditions requiring ongoing, complicated care. Applying this model to cancer care is right in step with their original intentions.
The oncology medical home model requires a standardized mechanism for providing enhanced patient communication and physician coordination of care; increasing patient access to care; monitoring preventive screening; having a standardized way of evaluating patients in the office; and a reproducible, reliable method of data collection and presentation to the physicians. It is all about increased care coordination, whole-person orientation, always measuring potentially avoidable complications, and addressing symptoms early—before they become major issues that can result in an emergency department visit or hospitalization. It also in volves educating patients about selfmanagement of common symptoms, and helping them to coordinate care beyond the medical oncology office through patient navigators.
NCQA’s 9 Key Requirements for a Medical Home
Q: How do you address symptoms earlier than in other care models?
Dr Sprandio: It begins at the time of the patient’s orientation to the practice. Our model truly engages our patients and their families. Patients are educated from the beginning about their responsibility to report symptoms. They are also given access to a telephone triage service that is very popular and well executed.
We have about 30 different symptom algorithms that our nurses follow. When patients call into our office about a symptom, they are immediately connected to a nurse. She accesses all of their data and can quickly assess the situation and provide standardized recommendations. We track the result of every clinical call that comes to our practice. Last year we had 3900 symptom-related calls from patients. Of these calls, 76% of cases were managed over the phone, 4.2% were sent to the emergency department, about 5.5% were brought into the office that day, and another 4.5% were told to come in the next morning.
We focus on early symptoms of potential complications, and our patients are indoctrinated to call early in the day. Our common phrase is, “If you wake up at 8 AM and you think you may have a problem, call us at 8:15 AM, not 4:15 PM.” Patients are also told that if they call and utilize our service, they will avoid wasting 8 hours in an emergency department and potentially having unnecessary testing or being admitted inappropriately.
Q: Do patients actually call the office with early symptoms?
Dr Sprandio: The more we engage patients in this model, the more calls we have received. For example, 5 years ago we only had 1200 or 1300 calls; last year we received 3900 calls. Our patients love it and never hesitate to call. They know they will have a live person on the phone who is a welltrained oncology nurse, with access to their complete data. Because their complete records are available in front of the nurse taking the call, patients know there will not be unnecessary questions. We engage them and give them access to prompt, accurate service that is painless and efficient.
Q: What role did electronic medical records play in your ability to establish the medical home?
Dr Sprandio: An oncology-specific electronic medical record (EMR) system is essential for ordering of drugs and other tasks. Most of the EMR systems have not been developed to enhance information sharing. We installed our EMR system in 2004, and quickly learned that it had major deficiencies. We ended up developing a software overlay to add data from the oncology-specific EMR, and this has enabled us to standardize our communication processes. For example, 2 years ago the turnaround time for a document to be completed and sent from our office after a visit was 28 days; the turnaround time now is <1 day. We can communicate within 1 day, or even within an afternoon, with other physicians who may be dealing with a very complicated patient. Our ability to communicate and coordinate care has increased exponentially, which is crucial when dealing with patients who are this ill.
We have contacted many of the larger technology providers, but they are preoccupied with the HITECH Act’s meaningful use requirements and cannot address our needs right now.
We did not create shortcuts for our physicians to complete their documentation; we created efficiencies: before we see a patient, all the data we could possibly need for that visit are available to us in a formatted way that we are used to, and that we utilize consistently. I saw 32 patients today: all my correspondence and documentation is not only done by now (4 PM), but it has already been sent to all the referring doctors for those 32 patients. In the past I would not be finished with that until late at night, the following day, or on the weekend. We have eliminated our transcription costs, streamlined the number of employees we have, and changed the job description for a lot of employees.
Q: How do you perceive the value of the medical home?
Dr Sprandio: Value is in the eye of the beholder. Patients see very organized, comprehensive, and consistent care coming from our practice. They love to have access, the patient-centered service, and they love the information they receive. We also have a patient portal, where they can pull up their progress notes.
Regarding the cost value of this model, if patients have fewer office visits, they also have fewer copayments. We have generated data that demonstrate that our total number of office visits per chemotherapy patient per year has decreased by 12% over the past 2 years. Patients have fewer visits, less inconvenience, and fewer copayments.
Payers see value in that we have reduced emergency department utilization by 65% since 2005 for patients receiving chemotherapy, and reduced hospitalizations for chemotherapy by 43% since 2007. The conservative estimate for the collective annual cost-savings to our payers is between $6.5 million and $10 million from our practice alone, and in excess of $9500 to $12,000 per patient receiving chemotherapy. There is no doubt that following chemotherapy pathways can save payers money. However, an international consulting firm interviewed us to assess the potential value of applying the medical home model to cancer care. They found that the savings from the pathways program is a finite number between 1% and 3% of the total cost of cancer care. They found that, by applying all of the medical home principles to cancer care, an additional 7% to 10% savings could be realized. This was using more conservative utilization targets than we had already achieved. We are not restricting care to save money; we are eliminating unnecessary resource utilization by screening patients more carefully and by providing better care. This saves money. Some people have asked about our clinical outcomes, because our patients spend less time in our offices, in the hospital, and in the emergency department. Our survival data are as good, or better, than those of a National Cancer Institute–designated Comprehensive Cancer Center.
Q: Are there reimbursement issues unique to the oncology medical home?
Dr Sprandio: Yes, and this is rather interesting. After standardizing and streamlining many processes, we became very efficient and our full-time equivalent employee-to-physician ratio decreased from 8.4 to 5.5, which saved a fair amount of money. That was great until about 18 months ago, when we noticed significant reductions in revenue as a result of fewer hospitalizations and outpatient visits. We also realized reductions in chemotherapy revenue because of more consistent, open, and honest discussions regarding end-of-life care. So this model creates an interesting dilemma for oncologists.
Our model should only be attempted by other oncology practices that can find payers who will be working with them to develop a reimbursement contract that will pay them for managing patients more efficiently. We have such a contract with a Philadelphia-area Medicaid HMO, and we are now working with a large national payer on a broader contract platform. There is no incentive for a practice to do what we have done as long as they are paid on a fee-for-service basis. They will get penalized for doing things more efficiently. It has not been easy to convince payers about the value of this model in oncology, because they all have various issues regarding their information systems and their data analytics. This model raises unique reimbursement issues. Everyone is very focused on the cost of drugs. The cost of chemotherapy drugs is only 26% of the total cost of cancer care. We are willing to focus on that cost, but we are also focusing more intently on the other 74% of cancer care costs, by keeping people out of the hospital and the emergency department, by keeping them healthier. Gradually, payers are beginning to respond to us positively. The interest is clearly growing from different health plans and from Medicare. The Community Oncology Alliance’s Oncology Patient-Centered Medical Home (OPCMH) demonstration project proposal submitted to the Center for Medicare and Medicaid Inno vation is based on our practice’s experience.
Q: Do you offer help to practices interested in your model?
Dr Sprandio: We have developed a toolkit that is now available to other practices, and we have utilized this toolkit to successfully initiate this practice transformation in a similarsized oncology practice in downtown Philadelphia. We are showing that it is reproducible. In addition to the toolkit, we offer an OPCMH practice readiness assessment and gap analysis, and provide software and support tools to aid in the transformation.
Through Oncology Management Services, we provide consulting services for health systems, payers, and practices working together, or payers alone. This is a step-by-step process that is like trying to feel your way through the dark. It will be a lot easier when this model is embraced by payers, and when we have a standardized contract with a national payer, which we expect to have in the next 6 months.