Growing awareness is prompting a revolution in vigilance and attention to detail that has significance both for the quality of care and financial health of practices.
Randall A. Oyer, MD
A patient who has a strong reaction to an oncology medication over the weekend and cannot reach their practice may be able to obtain care at an emergency department (ED) but might rack up unnecessary costs and receive inappropriate care from a physician who isn’t aware of their treatment regimen or implications for adverse events. That ED visit might also disrupt the care metrics that the oncology practice relies on to meet increasing standards for value-based care and payment incentives and penalties. Growing awareness of this situation is prompting a revolution in vigilance and attention to detail that has significance both for the quality of care and financial health of practices.
“When I talk to oncologists around the country, everyone is in a new cost consciousness,” said Randall A. Oyer, MD, medical director of the Ann B. Barshinger Cancer Institute at Penn Medicine Lancaster General Health and president-elect of the Association of Community Cancer Centers (ACCC). “Everyone understands the imperative of being good stewards of resources.”
The results of a recent ACCC survey offered a glimpse into how community oncology centers are affected by payers, government, and industry and are leveraging these challenges to come out ahead.1
Specifically, respondents identified what they considered the opportunities most likely to yield a return on investment and improve patient-centered care: care coordination (45%), more subspecialists (44%), symptom management (36%), and screening services (30%; Figure 1). In addition, clinical standardization, employment of newer drugs, and increased use of nonclinical staff were identified as significant opportunities for cost savings.
Some oncologists already take these steps as a matter of course. “These cost savings are all necessary for practices that are participating in the Oncology Care Model [OCM], the bundled care pilot established by the Center for Medicare & Medicaid Innovation,” Oyer said. “These are all definite musts to participate in the OCM. We are participating in the OCM, so we are doing all of these things.”
Better care coordination has been identified by the Institute of Medicine (IOM) as one of multiple national priorities for action to improve the quality of healthcare.2 Care coordination can take many forms—follow-up on medication adherence, appointment monitoring, hiring of clinical coordinators, establishing after-hours portals, holding care team consultations—and oncologists have been working harder on these points, spurred in part by the OCM and CMS’ growing, incentive-based emphasis on value-based care. Many factors impair coordination and contribute to poor outcomes. These range from poor follow-up on testing to electronic health records that don’t synchronize with other digital platforms (Figure 2).3
Privately developed models of care that emphasize better coordination have also emerged. The oncology patient—centered medical home has been touted as being able to save $1 million per physician per year. It can align systems and resources and thus reduce fragmentation, support shared decision making, and better control costs, according to chief architect John D. Sprandio, MD, chief of medical oncology and hematology at Consultants in Medical Oncology and Hematology and director of the cancer program at Delaware County Memorial Hospital, in Upper Darby, Pennsylvania.4
However, as with any transformative internal revamp, the model requires “nothing short of a substantial, disruptive, and coordinated response by the practice to reengineer the delivery of care,” as well as the creation of a sustainable business model that can be achieved only by actively engaging with payers in the development of new payment methodologies, according to Sprandio. Lighter measures are also available to achieve coordinated care.
One way is to hire nurse navigators, according to Mark Krasna, MD, who spoke on the subject at the ACCC’s 2018 annual meeting. Nurse navigators work with staffers and doctors at all levels in oncology practice and can help achieve consensus on an individual patient’s care, Krasna stated at the event. He added that care coordination reduces unnecessary x-rays and magnetic resonance imaging, among other tests, and puts practices in good stead with payers. He also noted that patient satisfaction is higher at facilities that work hard on aspects of care coordination. From a business perspective, these satisfied patients may help boost referrals by telling friends and family about their experience with the practice, Krasna noted.5
Care coordination cannot help but be beneficial for patients, Oyer added. A well-oiled system for patient referrals can add to the business benefits of coordination, which is helped along if oncologists pull out all the stops. “When you have a streamlined referral process, that is attractive to patients, and they are more likely to choose you to provide their care,” he said.
In a sense, care coordination is also workforce optimization, and that is good for running a business, Oyer said.
As oncology becomes more diverse and treatment more targeted, specialization as a strategy has attracted a following among practices that have adequate patient volume and physician resources. Almost half of ACCC survey respondents agreed that subspecialization is important for their practice. Departing from general practice brings both positives and negatives, according to experts.6 On one hand, subspecializing makes it easier to stay current and possibly increase quality of care in a focused area. It also promotes in-house consultation and referrals. The downside is that subspecializing possibly decreases level of care in other areas. It also may not be practical or possible in small practices or in rural areas with low patient volume, and making it succeed may require a group compensation plan that reduces competition for patients among physicians. Finally, it could exacerbate workforce shortages by concentrating efforts in a single area of practice to the detriment of another.
However, for larger practices, subspecialization can be the right move, and this seems to be the trend, according to Lalan S. Wilfong, MD, medical director of quality programs at Texas Oncology in Dallas. “We have subspecialists, and in this era of consolidation, it is rare for a physician to be in a solo or small practice,” he said, adding that subspecializing prevents hemorrhaging of patients to other clinics due to gaps in specialty knowledge. “Having subspecialists is also a defensive strategy to mitigate loss of the referral base, so that is the business side of it.”
A clinic that subspecializes can make the claim that its care menu is comprehensive, which is a selling point, Wilfong said: “You can start offering full services to patients. Offering a full women’s healthcare service means that a breast cancer patient can get all of her treatment from physicians who are coordinated and working together.”
A woman with high-risk breast cancer could get imaging done and see a medical oncologist, a radiation oncologist, and a surgeon during the same visit and all in the same building. “That’s kind of the ideal nirvana, to offer services that way. Instead of the patient having multiple visits and having to come back on multiple days, the physicians can all come together and plan decisions about her care,” Wilfong said.
Patients with advanced cancer typically have multiple concurrent symptoms that often cause them to seek out emergency care that could have been avoided by having a doctor on call or other measures in place. For practices that anticipate these problems and develop effective and economical strategies for managing them, the rewards can include practice economies and improvements in quality of care.
Symptom management is built into the OCM and is “something that we are giving great deal of attention to,” said Sibel Blau, MD, a medical oncologist with Northwest Medical Specialties (NWMS), PLLC, in Tacoma, Washington. “We need to better identify patients who are at risk for either emergency department admission or hospitalization, or even mortality, and try to bring them to the clinic early and control their symptoms.”
Symptom management is almost like screening, she added: “It’s like finding an early breast cancer. If we focus on managing symptoms, we can save lives and improve quality of care and, by doing that, lower the cost.”
The Center for Blood and Cancer Disorders (CBCD) in Fort Worth, Texas, has developed a symptom management triage pathway that is supported by information about patients that has been entered into the electronic health record, according to Ray D. Page, DO, PhD. When patients call in, their call goes to a centralized nursing center where the nurses use a scripted physician- approved management of symptoms algorithm. “They follow the script and ask the right questions, and within the scope of this practice, they can make the determination of what needs to be done, whether it’s a trip to the emergency department or if a prescription needs to be called in over the phone,” Page said. “It has been very successful, and we are expanding those pathways into many other cancer centers around the country.”
NWMS and CBCD recently implemented a common technology solution that merged symptom management and triage pathways and enabled them to reduce ED events by 222 in a population of nearly 5000 patients, for an estimated savings of $3.85 million over 6 months.7
For each care-management event, a ticket was opened, with nurse triage assigned to resolve critical issues. The process generated over 10,000 tickets and prevented many unnecessary ED trips.
The study demonstrated that physician- scripted symptom-management protocols and telephone triage pathways were key to the success of this program.
Besides nurse intervention and physician-generated protocols, other resources have been drafted for symptom management. “One thing that we are doing and that is receiving intense interest now is using artificial intelligence to characterize and identify the most highrisk patients,” Page said. “We’re now doing a pilot project with an AI [artificial intelligence] company and looking at 7 different vectors that can identify patients at high risk of decline.”
The program examines 4000 variables, some of which can identify which patient may need ED services in the next 6 months, who is at risk of depression, who will develop pain and may need an opioid, and who is at risk of mortality within the next 30 days. “We have been using it now for the past 8 or 9 months— we can interact with the patients who are at high risk and follow up with them,” Page said.
A chief advantage of symptom management is its versatility, according to Oyer. “It is being able to provide care in the lowest setting—if something can be done in the home, it should be; if something can be done in the office, it should be done there; and if something needs to be done at the hospital, then the patient needs to go there,” he said. “We should try to optimize care and keep it out of it the hospital, and that’s good business and also good for patients and families.”
When it comes to improving return on investment and patient-centered oncology care, screening for primary cancers ranks high on oncologists’ list of priorities. Roughly a third of respondents to the ACCC survey mentioned screening services as a top opportunity for improving on these metrics.
Screening goes hand in hand with subspecialization, according to Wilfong. At Texas Oncology, oncologists are considering adding breast imaging to their services to improve comprehensiveness of care offerings. The idea is to have a complete women’s healthcare center, where patients could come for screening mammography and receive other resources, if needed. “If a woman does have an abnormal screen, all of the other services are right there,” he said.
As far as screenings for prostate, cervical, and colorectal cancers, among other tumor types, Wilfong explained that Texas Oncology does not plan to expand their business model in that direction, mainly because they don’t have those subspecialists in place. “We don’t have a gastroenterologist, and although we do have a urologist, prostate cancer screening should, ideally, be done in the primary care setting,” Wilfong said. “The reason we are looking at mammography is that we do have a breast surgeon, so we could offer full care to a patient who had an abnormal mammogram and needed further workup.”