Innovative Cancer Care and the Initiation of the COME HOME Medical Home Program
By John McCleery
It has become apparent to all stakeholders in the oncology service sector that the increasing shift of site of care to the outpatient hospital setting from the community oncology practice setting is not cost effective. Recent papers published by the Moran Group (May 2013), Avalere Health (May 2012), and Milliman (October 2011) all contend that treating patients with cancer and managing their side effects in the outpatient setting is more costly to Medicare, an already strained system, than it is to treat in the community practice setting. The Moran Report found that from 2005 to 2011, that Medicare fee-for-service (FFS) payments in the hospital outpatient setting (HOPD) tripled from $98.3 million to $300.9 million for chemotherapy infusion, while payments for physician office infusions decreased by 14.5% from $507.5 million to $433.8 million.
Consolidation of community oncology practices into groups and/or hospitals or academic centers may be partly to blame for the increase in the number of Medicare fee-for-service payments to the HOPD setting and the decrease in office infusions. In June 2013, the Community of Oncology Alliance (COA) reported an increase of 20% in oncology practice closures since their last reporting on the state of community oncology practice settings. COA cites the reasons for the closures as due to “insufficient Medicare reimbursement to community oncology clinics and higher reimbursements and margins to hospital outpatient facilities, especially those eligible for 340B discounts.”
While the debate over Medicare sustainability continues and with provisions provided by the Patient Protection and Affordable Healthcare Act, new models are emerging in the oncology practice setting to support appropriate care for cancer patients while also providing sufficient compensation to providers to deliver the many services that are necessary to the care of their patients. Proponents of the patient-centered medical oncology home model are setting out to prove that the model can save Medicare money by overhauling the mindset of the patient-provider relationship when it comes to managing patients with cancer and the subsequent side effects associated with that care. At least that is the goal Barbara McAneny, MD, CEO, New Mexico Cancer Center, addressed at the recently held Cancer Center Business Summit (CCBS), where she introduced the mechanics of the COME HOME program.
With the $19.7 million grant she was awarded by CMS to Innovative Oncology Business Solutions, Inc, (IOBS) a company she started, McAneny will aggregate data from the COME HOME project and compare that data with Medicare claims data from the same time periods and note the differences in cost between the sites of care and reflect the savings. The COME HOME program is dedicated to delivering comprehensive outpatient oncology care to patients while lowering costs of care by keeping patients out of the ED and away from being admitted as an in-patient unnecessarily. Dr. McAneny recruited seven cancer centers located across the country to participate in the COME HOME program.
The seven practices associated with the COME HOME program are the New Mexico Cancer Center, Austin Cancer Center, Northwest Georgia Oncology Center, Dayton Physicians Network, The Center for Cancer and Blood Disorders, Space Coast Cancer Center, and the Maine Center for Cancer Medicine (MCCM).
The first practice went live in May 2013 and the seventh practice went live in August 2013. Together, the practices plan on demonstrating that they can save CMS up to $34 million. This will be done by aggressively managing the side effects of cancer and its treatment, and by improving the quality of care through triage protocols, which includes team-based care, and the development of clinical pathways. Currently completed pathway protocols are pancreatic, breast, lung, and colon cancers; lymphoma and thyroid pathways are in progress, and melanoma is expected to be completed by the end of 2013.
In addition, from an office staffing point of view, patient-centered care involves centralizing the phone system, extending office clinic hours beyond 9 to 5 and having clinic hours of operation on weekends. Same day appointments for antibiotics, fluids, and acute follow-up of reported symptoms are also incorporated, as is patient education and the development of a patient portal. The entire healthcare team is expected to perform at the top of their skills.
The reconfiguring of the patient/provider mindset and the aggressive management of cancer treatment and its side effects are at the core of the COME HOME model to keep patients out of the ED and avoidance of unnecessary hospitalizations.
Triage Pathways are at the heart of the COME HOME program. So when patients call into the call center off hours, they will not get a recording telling them that if this is an emergency to call 911 or report to the nearest hospital, and instead they will get a live triage nurse who has a scripted response for what is troubling the patient.
“Triage pathways are a way to figure out what is needed in that given circumstance and not have to think it through every time,” McAneny told the audience during her presentation. The pathways are designed to getting the patient the right care they need at the right site of service at the right time.
The triage pathways developed by McAneny and colleagues, manage a total of 22 symptoms that include nausea, fatigue, rash, and headache, plus follow-up assessments. Each practice in the COME HOME program will receive funding in order to implement the triage pathways, and compliance will be monitored by software tracking systems.
“Everybody has to understand,” McAneny said, “if you want a job in one of our practices you have to figure out what a patient needs [when they call in for assistance] and get it to them as quickly and as efficiently as possible.” Not that the pathways allow patients to run the system, “They’re the sick ones,” she iterated, “and just need to be taken care of.”
It was explained by Laura Stevens, Business Director/CIO of IOBS that when recruiting, they looked for practices to join their network that were efficient and innovative.
“They had to have a fully functional EMR,” she said as “the data [they collect] must be meaningful and accurate, and any area of deficiency must be identified and corrected immediately.”
“It’s a team based care,” she said, and everybody has to use their own skill set to make the appropriate decisions without having to check in with the physician and inform him/her that a patient just called in, has a fever, and wants to know what to do. With the triage pathways in place the nurse will have the authority to make the appropriate decision as to the next right step in the care of that patient.
Innovative Cancer Care and the Initiation of the COME HOME Medical Home Program (cont.)
In phase 1 of the COME HOME model, patient services include:
- Patient education and medication management
- 24/7 practice access
- Telephone triage
- Triage pathways
- Night and weekend clinic hours
- On-call physicians
- On-site or near-site imaging and laboratory testing
- Admitting physicians who shepherd patients through inpatient encounters, avoiding handoffs and readmissions, and ensuring seamless care
Software programs will allow monitoring of how well physicians in each practice are managing patients. Compliance rates with pathways will be measured as will expenses of the care. The software will allow the lead physician at each practice to review and discuss with colleagues how they are doing and where improvement needs to be implemented. Physicians will be paid a set amount instead of fee for service.
The projected savings to CMS are shown in the table.
Case Study: The Maine Center for Cancer Medicine
The Maine Center for Cancer Medicine (MCCM), a private physician-owned practice for over 30 years, with operations in four sites, is one of the 7 practices included in the COME HOME medical home program. Addressing the audience at the CCBS, Tracey Weisberg, MD, President, discussed the difficulties of transitioning from a primary nurse model to a medical home model.
“Our vision has always been to provide the highest quality, cost effective cancer care in the region,” she said. One of the tools that helped MCCM achieve this goal was the implementation of an EMR system. MCCM is on their third system and “each one has helped us shore up our practices and improve care,” she said.
When MCCM was approached by Barbara McAneny as a potential COME HOME medical home site, Weisberg asserts that McAneny saw the building blocks at MCCM that could potentially help her deliver on her overall goal of saving money while improving care.
The basic tenet of the COME HOME program is to be present for the patient at the time of his/her greatest need. In order to do this, Weisberg said, “We needed to look at our staffing and see that everyone was doing their job at the top of their licensure.” One of the greatest challenges Weisberg said she faced was how to get her staff on board and make the transitions necessary to not only execute the tenets of the COME HOME program, but that would also take her organization into the reality of the patient-centered medical home mindset.
“We had an economically inefficient model of primary nursing for over 30 years,” Weisberg said, and that included a 9 to 5 working shift mentality. Transitioning from that model was difficult and was met with much resistance. The physicians at MCCM were enthusiastic, Weisberg said, but the nursing staff was skeptical about having to work extended hours and on weekends.
“We had a much-loved lead nurse who could not envision any kind of change, not in hours, and not in a phone system revision, and it eventually cost her, her job.” This put an added level of disruption to the transition that MCCM is still feeling the effects. Many of the nurses had a perception that “there was a perceived rigidity of following an urgent care pathway” which they said they were already following, but Weisberg disagreed.
The frustration Weisberg met, ultimately led to a breakthrough and the urgent care hours were eventually implemented. With the new phone system in place, every phone call is now documented and “we are able to gather data about what happens on that call and the outcomes” associated with that call.
In the absence of a lead nurse, the remaining nurses got together and created a new nursing council that reviews all of the protocols needed for the successful functioning of a medical home. Reaction to the new program has been enthusiastic.
“Once we implemented our extended hours, the patients have been deliriously happy. Especially for the weekend hours,” Weisberg said.
The model set in place by COME HOME has prevented many patients with cancer from going into the ER, Weisberg said. In fact, their hospital association that wants to use MCCM’s data to reduce their own ER admissions, and private payers have also expressed interest in their new model. “It’s been a huge win for everyone,” she said.
Summary of Key Points to the COME HOME Program
The BEST practices tools of the COME HOME program include:
- Use of Electronic Health Records to share/track real-time patient data and to monitor quality of care.
- Creation of triage, diagnostic, and therapeutic pathways.
- Team-based care that includes all of the members of a multidisciplinary care-team that is dedicated to practicing at the top of their license in order to keep patients out of the ED and unnecessarily hospitalized, through active disease management, patient education, and on- or near-site laboratory, imaging, and pharmacy accommodations.
- Enhanced access to the medical team with an open 24/7 triage line, extended weekday and weekend hours, same day appointment availability, and automated pathway follow-up reminders for triage nurses.
- Financial support for medical home services.