Jonathan Gavras, MD
As politicians on Capitol Hill pursue divergent visions for the country’s fractured healthcare system, a growing number of physicians, hospitals, and payers are quietly joining forces to explore new models to meet such shared challenges as rising medical costs and declining reimbursements.
In one notable collaboration, Advanced Medical Specialties, a multisite oncology practice in the Miami-Dade–region Florida Blue, the state’s largest private insurer, and Baptist Health South Florida, the hospital group, are forming a cancer-specific accountable care organization (ACO) that the partners contend will streamline the delivery of care, rein in costs, and improve outcomes.
ACOs aim to improve quality and efficiency by integrating clinical services and communications across practice areas, implementing evidence-based treatments, and keeping close track of care and outcomes through shared electronic medical record systems, among other measures. While conceived as a model for primary care, they are gaining attention in specialty areas such as oncology, where care is especially complex, management-intensive, and expensive.
“We have been seeing rapidly escalating oncology costs in a state with a high incidence of cancer. We are exploring ways to work collaboratively to build an integrated system where high-quality care provided to members will lead to more efficient care. In the end, this reduces the cost of care,” said Jonathan Gavras, MD, senior vice president of delivery systems and chief medical officer for Florida Blue.
Under the new organization, physicians will act as primary navigators who are accountable for patient care, while guiding patients through the healthcare system. When patients enter the hospital, they will retain “strong connectivity” with the physician group, Gavras said, through continuity of care, adherence to clinical pathways, and the use of electronic medical records. The healthcare plan will then aggregate information on the care provided and share those results with the hospital and physician partners. As they seek to contain costs, they will look closely, for example, at avoided emergency room visits.
The partners are instituting a shared-savings program they say will act as an incentive to reduce unnecessary services. In setting it up, they began by identifying a population of patients with common cancers, including leukemia, lymphoma, and breast, gastrointestinal, prostate, gynecologic, and thoracic cancers, and then examined the care they were provided over the course of a year and tabulated its cost.
Leonard Kalman, MD
“We looked historically at the cost of care for this population, and then set a budget per patient, per condition going forward for a year,” said Leonard Kalman, MD, chairman of Advanced Medical Specialties. “We’ll see if we can beat that budget, and if we do, the savings would be split. We’re still in the midst of looking at where dollars have been spent and identifying those areas where we think the cost curve can bend.”
In seeking efficiencies, Kalman said that his practice has focused on evidence-based treatment regimens, advance care planning for end-of-life care, and lowering the number of unnecessary hospital admissions, as well as emergency room visits. The practice employs “chemotherapy educators,” for example, to meet with patients before they receive their first course of chemotherapy as a way of reducing emergency room visits and admissions related to side effects.
“Avoidable admissions are a top priority. We may need to create a lower-intensity triage area, possibly within our infusion suites, so patients don’t have to go to the hospital,” he said, noting that while these services are presently set up for weekday, daytime hours, the partners are exploring ways to avoid emergency room visits and admissions at night and over the weekend.
Access to electronic records, via secure networks over the Internet, will reduce medical errors and ensure that providers are not repeating diagnostic tests, Kalman said, adding that the group is currently working out privacy issues and logistics as it sets up the new system.
“We also need to encourage patients to consider advance care planning, working with doctors and nurse practitioners. This would include avoiding the use of chemotherapy, ICU, hospital or emergency room admissions for the last 30 days of life,” he said, noting, however, that both the health plan and the hospital system will need to “market” advance care planning if it is to be successful.