New Mexico Oncology Medical Home
Cancer care has been undergoing transformation in recent years. The oncology medical home is one model that has shown improved outcomes and patient satisfaction. What are the characteristics of the oncology medical home and how is it different from other cancer centers in the United States? Value-Based Cancer Care (VBCC) discussed these questions with Barbara L. McAneny, MD, CEO, New Mexico Oncology Hematology Consultants, who established the New Mexico Cancer Center’s Oncology Medical Home as part of the COME HOME award from the Center for Medicare and Medicaid Innovation.
VBCC: What are the characteristics of an oncology medical home?
Barbara L. McAneny, MD: The oncology medical home concept is centered around the idea of “home.” Home is where you go when you need help. The goal of the oncology medical home is to provide all the services that patients with cancer need to treat the cancer and manage the complications associated with cancer and its treatment, in the same place, and as quickly and as efficiently as possible. A patient with cancer does not have the energy to confront an inefficient system. It was crucial for us to establish an efficient system that will provide everything a patient with cancer needs right at our facility and avoid the need to use services at emergency departments or hospitals.
I thought about all the problems that confront a cancer patient and established policies and procedures to provide as many solutions to those problems as we could. Cancer treatment is done by a multitude of specialists, and patients are overwhelmed by the process of navigating the dysfunctional system. Part of what we do is to coordinate that care, when we cannot deliver it ourselves. However, as an oncology medical home, we need to be available when the patient needs us. For example, when patients call for help, they don’t need to hear, “If this is a medical emergency, hang up and dial 911.” When a patient has cancer, everything feels like an emergency. So if patients call the center and no one answers, they will indeed call 911 and will end up in the emergency department, where they may get unneeded care, such as an extra computed tomography (CT) scan or laboratory work that was already done at the cancer center. This leads to wasteful care that is also very expensive. Emergency physicians do a great job of handling medical emergencies, but they cannot be expected to know what happens with patients who have cancer, and how to manage chemotherapy complications.
VBCC: How is your medical home different from cancer centers that are not medical homes?
Dr McAneny: The most important thing we did was to change the triage system. A nurse who answers the phone and talks to the patient, I would contend, is not triage. Triage is when you actually figure out what the patient’s problem is, and then you provide the necessary treatment or service, immediately. Instead of trying to keep the patients out of the practice, because the practice was full that day, we changed our schedules and systems to allow the triage nurses to schedule service at the center the same day.
So first we rearranged our triage nursing culture and the mindset of every employee in the practice. Everyone had to say, “My job is to figure out what this patient needs, and how I’m going to get it for them.” That is crucial. We then made sure that our systems are set up to meet the patient’s needs at that time, so that if the nurse who is talking to the patient realizes that, for example, the patient had a fever or needed antibiotics, the nurse would invite the patient to come in to the center right then and there. Not tomorrow, not the day after. That makes a huge difference. And it requires that the center stays open late, and is open every day, including on the weekend.
We have implemented the COME HOME computerized triage system so that the nurse has the decision support to manage the symptom at the appropriate site of care. We do not want patients with heart attacks or with broken bones coming to the center, for patient safety and for medical liability reasons. The triage pathways are designed to avoid sending the patient to an inappropriate site of care.
If the center is not open when the patient gets sick, the patient will end up going to the emergency department and having an avoidable, expensive workup, when possibly all that patient needs is a liter of saline. This is why we provide urgent care levels of service on weekends, on holidays, and on weekday evenings.
So the most crucial aspect of an oncology medical home is the mindset that says, “My job is to get you what you need.” The second thing is the notion that we must have the infrastructure in place in the office to manage those complications directly. This is different from a primary care medical home, which must coordinate care given elsewhere but cannot simply provide it.
It is also important to have at the practice a physician, a nurse practitioner, or a physician assistant who could see the patient immediately, and get laboratory work back quickly, so that they can efficiently diagnose and treat the patient’s problem. At our medical home we can get laboratory work, x-rays, or CTs immediately, hydrate patients, give intravenous antibiotics, and provide many other services. That has also led us to be able to manage well patients who had fairly serious conditions, such as pulmonary embolism or neutropenic fevers, right at the practice rather than send them to the hospital for prolonged stay, where they could catch resistant bacteria, develop blood clots, or become debilitated from lying in a hospital bed. Our patients are very grateful, because they do not have to spend time away from their home. For a patient with cancer who has a limited time remaining to live, the last place that person wants to spend it is in a hospital.
VBCC: How many physicians are in your oncology medical home, and who is there after hours?
Dr McAneny: My practice has 17 physicians, including medical oncologists, radiation oncologists, radiologists, and a few internists. After hours we become a symptom management facility. If a patient has a fever, nausea, diarrhea, or pain—all the things that bring patients with cancer to ask for care—we provide that care, but we do not provide oncology care, such as chemotherapy infusion or radiation. Our internists or our midlevel oncology providers are in the office after hours. Our oncologists are not working extended hours. We match the staff to our peak time, and we hired very few additional staff when we extended the hours. We have 2 nurses, a person to manage the phones and draw blood, a radiology technician, and a physician.
VBCC: The current economics force many oncology practices to join hospitals. Do you have any suggestions on how to reverse this trend?
Dr McAneny: The key here is to connect with payers. This is ironic. We have always spent our time arguing and negotiating with payers, trying to avoid reductions in payment. Now, payers are recognizing that as oncology practices move to the hospital, if it is a Medicare patient, the prices go up 50%. If it is a patient in a commercial plan, the prices can increase between 200% and 300% over the price they were paying for the exact same service in the physician’s office: the same quality, same service, and sometimes the same physician.
It is a question of what fee schedule the physicians are being paid under. Payers are beginning to realize this with the increasing trend of hospitals acquiring oncology practices. Hospitals love it, because they can often get 340B drug pricing, and it becomes a big “cash cow” to the hospital. The hospital can bill the insurance company more for the same service. The economics are driving practices into the hospital. The way to stop this is a payment reform that will pay the same amount across different sites of service, and to return the 340B drug program to Congress’ original intention of providing care to uninsured people.
A 15-minute office visit or a 1-hour infusion of a drug should cost the same whether the practice is organized under a hospital and is therefore paid under the hospital outpatient’s payment system, or whether the practice is organized as an independent physician office that is paid under the physician fee schedule.
That would stop the trend of oncology practices joining hospitals in a heartbeat, because hospitals are not very good at running outpatient practices. Rather, they were designed to manage complicated inpatient visits that need multiple specialties working together for sick patients.
VBCC: Do you recommend to other practices to adopt the oncology medical home model?
Dr McAneny: Absolutely, for 3 reasons. First, the oncology medical home provides better care for patients. Patients are thrilled to not be in the hospital. They want as good quality of life as they can get. Being home, and having their problems managed aggressively add to that quality.
The second reason is that it saves costs for the entire US healthcare system. We cannot afford to spend more healthcare dollars. If we can deliver better care at a lower price, we must do so.
Third, we are soon going to move away from the fee-for-service model (I believe within the next 2 years), at which point we will be moving to bundled payments. A practice that cannot manage the expensive parts of patient care will not be able to succeed under a bundled payment system. The oncology medical home model can better deal with this payment system