Patient-Centered Oncology Medical Home Improves Health Outcomes at Lower Costs to Patients and Payers
Los Angeles, CA—Oncology practices are evolving in an era of cost containment and a renewed focus on quality. At the Fourth Annual Conference of the Association for Value-Based Cancer Care, John D. Sprandio, MD, Chief of Medical Oncology and Hematology at Oncology Management Services, Ltd, a single-specialty practice transformation company, discussed how his Pennsylvania-based integrated care delivery model has evolved to meet the parallel needs of oncology payers and patients with cancer.
Cancer care is undergoing transition. Community-based oncologists have gone from providing approximately 85% of the cancer care in the United States to probably less than 60%.
“It is happening because payers are now beginning to allow us to make a business case for quality, and changing the way that we deliver care and allowing us to provide a new value proposition,” said Dr Sprandio.
Oncology Management Services was recognized (in 2010) as an oncology patient-centered medical home (PCMH) through the Physician Practice Connections program. The model enables the medical oncology practice to serve as the focus of coordination and accountability. The oncology PCMH is integrating surgical, radiation oncology, inpatient, social, and hospice services. The value proposition of PCMH is better cancer care and better health, at a lower cost.
“There’s payer recognition,” Dr Sprandio said. Payer interest in this model is still climbing. Many quality and value drivers characterize the oncology PCMH (Figure 1).
The primary drivers are the services provided by the oncology physician-led team. Secondary drivers include process-of-care standards, such as the patient-centered oncology care standards and the American College of Physicians’ PCMH Neighbor concept.
“The desired outcomes are truly payer- and patient-centric outcomes,” said Dr Sprandio. “It’s one of the unique times when payers’ and patients’ desires and goals are really overlapped….It’s not completely overlapping sometimes, but it’s pretty close. The right drugs, the right care, the right surgery, and so on. Prompt palliation of symptoms. Keeping people healthier, treating them in a more timely fashion when they have symptoms to reduce potentially avoidable resource utilization, consistent survivorship care, and rational care at the end of life.”
As an example, metrics regarding the group’s oncology nurse triage phone line demonstrate financial and patient care benefits. “One of the keys in making this work was to engage patients and their families to become excellent, very vocal, very frequent reporters of symptoms,” Dr Sprandio said.
In 2013, our oncology PCMH, Dr Sprandio said, had approximately 5106 symptom-related phone calls, 84.21% of which were managed at home by the nurse (or the nurse in conjunction with the doctor) who was trained by following Oncology Management Services’ algorithms (Figure 2).
Approximately 7.5% of patients were seen within 24 hours. In the first quarter of 2014, 78% of all symptom-related patient calls occurred from 8:00 am to 6:00 pm during the week; the other 22% came on the weekend and in the evening.
The busiest day for unscheduled visits was Friday. “Patients are told that if they’re going into Thursday night, and they might need a “tune-up” to get through the weekend, they come in Friday,” Dr Sprandio said. “We have patients who we see on Monday and Tuesday who are fragile. We give them a tentative appointment for Friday to potentially get them through the weekend.”
Emergency department utilization for patients receiving chemotherapy was reduced significantly, from an average of 2.6 annually in 2004 to 0.765 in 2012. “We think that is because our processes are so standardized with each visit that they’re more complete,” Dr Sprandio said. “There are things that are…less often overlooked.”
Dr Sprandio noted that physician and practice efficiency have also improved through conversion to an oncology PCMH model. The practice went from 8.3 full-time employees per physician in 2007 to 5.6 in 2013.
Oncology Management Services now has 3 alternate payment methodology payer contracts that cover 54% of the practice patient base. “We have an enhancement of fee for service in some of the contracts, a per-member per-month payment for the sickest subpopulation. We have a shared-savings equation in all 3 of the contracts. Then we have some precertification relief, which is helpful too,” he said. Revenue enhancement has also been realized from improved documentation and coding, improved physician efficiency, and new referral patterns.
The transition from fee for service to the PCMH occurs in 3 phases. Phase 1 involves reengineering the delivery of care, during which policies and processes of care delivery are standardized and the telephone triage algorithms are implemented. This phase took up to 6 months. Data submission for recognition constitutes phase 2, with a timeline for completion of 4 to 8 months. Phase 3 consists of quality improvement, including continuous improvement (compared with regional peers) in guideline adherence, utilization of diagnostic and laboratory services, end-of-life care, and hospice, among others.