Lalan Wilfong, MD
About 5 years ago, Texas Oncology moved to improve accountability and pathways compliance by introducing a pay incentive that put 2% to 3% of a physician’s pay at risk. The amount at stake for failure to achieve benchmarks was not huge, but the program worked, according to Lalan Wilfong, MD, who has served as administrator. The physicians had children’s private-school tuition and other large expenses to pay, and they were highly averse to any loss of income. “It really didn’t take a lot to have physicians’ anxieties raised enough to help with that pathways process,” said Wilfong, who discussed the incentive program at a recent meeting of the Community Oncology Alliance. With 420 physicians and 175 practice sites at Texas Oncology, there was much potential for divergence in pathways conformance. The oncology chain established an 80/20 rule: 80% was considered the optimal pathways adherence rate, and it was recognized that physicians would need to deviate about 20% of the time to address unusual patient cases. Under this system, physicians who achieved at least 75% compliance would receive 100% of their pay. After the incentive plan and the support tools were instituted, the compliance rate rose from the prior level of 78% to 89%, Wilfong said.
The system also turned out to be an adequate incentive to get physicians thinking about improving their performance metrics, including hospitalization and emergency department (ED) visit control, advanced care planning, and shared decision making. But developing a workable system was complicated, Wilfong said.
Some physicians had their own ways of doing things, based in part on their training. In addition, new drugs were expected to emerge that physicians would recognize as superior treatments long before they were incorporated into pathways. Further, when deciding to hold physicians accountable for costs and outcomes, it was necessary to know their limitations and understand what was beyond their control, Wilfong explained. Higher patient hospitalization rates are to be expected in some medical specialties; and physicians who do transplants are less likely to follow pathways because of the uniqueness of the patient populations they work with. “Their pathways performance is very poor,” he said.
To address these situations, Texas Oncology instituted a review process. Physicians who want to go off pathway must explain why to their clinic’s medical director. If there is still a disagreement, the physician can go before an exception committee. “What I tell my physicians all of the time is, you should be able to stand up in a room of medical oncologists who are all reasonable, rational people and convince half of them that what you’re doing is correct; and if you can’t stand up in a room and convince half of us that what you’re doing is the right thing for your patient, then you probably shouldn’t be doing it,” Wilfong said. In addition, an approval for an off-pathway choice of treatment is needed before the dispensary will mix a related chemotherapy formulation.
Also, Texas Oncology has sought to avoid overcompliance with pathways, as it can signify that a physician isn’t paying enough attention to a patient’s needs. Wilfong said he was reviewing the records of some physicians in his group who are 100% compliant with pathways. It’s important that physicians act appropriately when an established treatment path is not ideal for a particular patient, Wilfong said, adding that fear of deviation also should addressed. “I want to make sure that the physicians feel comfortable recognizing those times when it is appropriate to look at nonpathway-based therapy.”
The information that CMS has dispensed to support practices enrolled in the Oncology Care Model (OCM) has yielded a wealth of data on rates of hospitalization and emergency department (ED) use, Wilfong said. It revealed much variability in the way patients were being managed. Administrators plan to make hospitalization rates a factor in calculating bonus pay in the future, but for now they are working with individual treatment centers to better control rates of hospitalization and ED use. This may involve, for example, ensuring that patients’ phone calls are answered and an effective triage system is in place “so a patient doesn’t sit there in an emergency department because somebody didn’t call them back,” Wilfong said.