James Talcott, MD
At first glance, North Star Lodge would seem to have little to gain by upending its operational flow and embracing the Oncology Care Model (OCM) and its form of patient-centered, outcome-based care that costs providers time and money up front.
The Yakima, Washington–based practice faces little competition. It is the sole provider of cancer care in a rural 6-county region that encompasses the Cascade Mountains to the west, the Yakama Nation reservation to the south, and highly productive farmland to the north and east.
It also serves a population that is geographically ill-suited to frequent office visits and has language issues. Roughly a quarter of North Star’s patients live more than 30 miles from the nearest of the clinic’s 3 offices, more than 40% grew up speaking a language other than English, and more than 10% don’t speak much English. Patient incomes are also significantly lower, on average, than those of Washington state residents overall.
Yet North Star believes that outcome-based, patient-centered care holds the potential to improve results for its patients, so it has committed itself to the new model. It is 1 of just 2 Washington-state practices and 1 of very few rural practices anywhere in the nation to participate in the OCM. North Star’s involvement is a test of the model’s adaptability: Can patient-centered care deliver results in a largely rural setting, even among disproportionately low-income patients for whom English is not their native tongue?
“We’re about a year in, and we’re all enthusiastic about where we’re headed, but practices that are considering the jump to this care model should realize it’s not a magic bullet. Hospital usage and emergency department [ED] visits don’t plummet overnight,” said James Talcott, MD, who is leading North Star’s efforts to implement the new model. “Every time you take what seems to be a highly logical step to improve care or eliminate waste, it tends to create another unforeseen problem down the road. You have to fix a lot of problems to clear the entire road.
“For example, there’s a big shortage of primary care providers around here, so everyone has spent decades going to the ED whenever they can’t wait a month or 2 for a doctor’s appointment. We’ve expanded our hours and added extra appointment times, but many patients still go to the ED, especially those who live closer to an ED than they live to us.”
North Star is not an independent operation. It is an outpatient unit of Virginia Mason Memorial, a 67-year-old, not-for-profit organization that is both the Yakima region’s largest healthcare provider and its largest employer.
The practice owes its name to its main facility, which resembles a log cabin that might be found at the base of a ski resort. Memorial built it in 2000 as part of a campaign to expand and improve its cancer program, giving Yakima-area residents a relatively nearby option for cancer care that previously required a 2.5-hour drive to Seattle. North Star now has 6 medical oncologists and 3 radiation oncologists who work with hospital surgeons to provide most forms of cancer treatment and most common surgeries to about 5000 patients per year.
That patient population is divided about evenly between whites and Hispanics, with each group making up about 46% of the total. Native Americans make up just under 2%, with the remaining 6% divided among all other nationalities and ethnicities.
The Importance of Financial Navigators
North Star’s catchment area includes a large number of affluent farmers, but the median household income is still less than half of the Washington state average. That means that a substantial number of patients have already benefited from at least 1 aspect of the OCM model: financial navigators. The practice now has 5 full-time staff members who look for ways to save patients money and fund the care that North Star provides. Each time the practice begins treating a patient with no insurance, lackluster coverage, or the inability to meet co-pays, these navigators look for programs that can help, such as available insurance options, philanthropies, and pharmaceutical company programs.
North Star’s low-income patients also benefit from the state’s decision to expand its Medicaid program under a voluntary component of the Affordable Care Act. Since the beginning of 2014, coverage has been available to Washington families whose incomes are as much as 33% above federally calculated poverty thresholds. Expanded eligibility has increased the state’s total Medicaid population by 690,332, for a total of 1.8 million. The combination of the Medicare expansion, an improving employment climate, and other factors reduced the number of uninsured people in the state by 62% over the same period.