Oncology Medical Home Pilot Improves Outcomes
Los Angeles, CA—Wilshire Oncology Medical Group President Linda D. Bosserman, MD, discussed the group practice’s oncology medical home pilot of value-based innovation at the Fourth Annual Conference of the Association for Value-Based Cancer Care.
The Wilshire Oncology Medical Group, Inc, is a collaborative independent oncology practice in California that currently consists of 5 private clinics. The group serves a large patient population, including the indigent, who comprise 25% of the population in the counties covered.
The group has 8 medical oncologists, 2 radiation oncologists, and 10 midlevel providers. “We have pioneered…the partnership with the midlevel provider with the clinicians, so patients know they have a team wrapped around them to meet their needs at every possible time point,” said Dr Bosserman. Each full-time physician works at approximately 1.7 times the national average.
The turning point for Wilshire Oncology came in 2005 when the capitated independent practice association (IPA) that served them terminated its contract. It forced Wilshire Oncology to figure out how to take care of patients for the budget offered by another large IPA, leading to the oncology medical home pilot.
Implementing Patient-Centered Care
Along with implementing electronic health records, Wilshire Oncology sought to improve efficiency and quality by examining National Comprehensive Cancer Network (NCCN) guidelines, leading to the development of patient-centered, value-based cancer care. The goal was to provide evidence-based, validated, outcomes-driven quality patient care. This type of quality care also has to meet national quality standards that follow cost-effective pathways to provide access and affordability to patients. The delivery system has been optimized to follow efficient pathways.
“We developed structured things for patients and then payers….Every chemotherapy visit has a structured education, so we can actually ask about fertility,” Dr Bosserman said. “In case the doctor forgot, the nurse asks every patient about fertility. It’s in the intake form, but it’s also in the chemotherapy education and the chemotherapy consent form.”
Practice changes targeted prevention. “We’ve always done 3-generational family histories,” she said. “We do integrated genetic evaluation and risk management at the time of making a consultation. I don’t see how you see a breast cancer patient that’s 30 with 3 family members with breast cancer and 2 with ovarian, and not talk about her risk as part of the comprehensive treatment planning.”
Care management and coordination is focused on interval care management when a patient is receiving therapy, and also on tertiary, emergency department, hospitalist, and subspecialty cancer care.
“We have case care management and coordination, so when you’re on a treatment plan, we educate you about it,” Dr Bosserman said.
After the introduction of the medical home pilot, the percentage of patients with metastatic solid tumors who received colony-stimulating factors was reduced markedly, consistent with recommendation from the American Society of Clinical Oncology.
Pathway adherence topped 90% among patients receiving chemotherapy-biotherapy or hormone therapy only; if there was an NCCN pathway, 99% of patients were managed according to the pathway, and if there was a level 1 pathway, 92% were managed according to it.
Wilshire Oncology directs cancer care from the outset, with an emphasis on patient engagement, including asking patients about medications, new diagnoses, pain, and symptoms via a 39-point questionnaire. Patients are encouraged to rate their symptoms using National Cancer Institute common toxicity criteria.
Symptom care is proactive and reactive, and the site of care is optimized to minimize emergency department visits and hospitalizations. By year 2 of the medical home pilot, emergency department visits for patients with breast cancer and other solid tumors who were receiving chemotherapy were reduced to approximately 25% of the rate before the pilot (Figure 1).
Hospital admission by tumor type was reduced by more than 50% in years 1 and 2 of the pilot compared with prepilot (Figure 2).
Supportive care and end-of-life care are also part of the oncology medical home. Some 94% of the patients have had a discussion of advanced directives, Dr Bosserman said. Palliative and hospice care are integrated into the medical home to minimize intensive care unit and hospital end-of-life care.
Payer engagement is essential for value and is possible by aligning incentives to staff for patient-centered care. Payers must be made aware that care planning, management, and coordination, along with cost-effective drug regimens, a tailored information technology infrastructure, and data analytics, are crucial.
Wilshire Oncology was successful in getting Anthem Blue Cross and Blue Shield to turn its focus from medication costs to care planning and management. “They are going to nationally start paying for care planning and care management with their ‘S’ codes using guidelines,” said Dr Bosserman.