In response to the billions of dollars wasted each year in the United States on fragmented, ineffective, and uncoordinated care, some healthcare reform efforts have focused on integrating the delivery of healthcare.
Mark Hornbrook, PhD
In response to the billions of dollars wasted each year in the United States on fragmented, ineffective, and uncoordinated care, some healthcare reform efforts have focused on integrating the delivery of healthcare.1-3 Today, millions of Americans receive their healthcare from integrated delivery networks (IDNs).1,4
However, just what is an IDN? Today, there really is no single answer.4 “The phrase covers a spectrum of scenarios; it has not been defined and is actually used as a catchall phrase to cover a variety of types of healthcare arrangements,” explained health economist Mark Hornbrook, PhD, researcher with the Cancer Research Network and senior investigator and chief scientist at the Kaiser Permanente Center for Health Research in Portland, Oregon. Integration might take place vertically, across different levels of care, or horizontally, such as occurs with hospital mergers.1
In practice, an IDN might coordinate and standardize clinical care, disease management, financial management, and human resources across all of its providers and facilities. Some IDNs develop and employ patient care strategies with the end goals of cost-effective improvements in health outcomes, quality of care, and efficiency.1 Evidence demonstrates that patient care strategies are more likely to be used by IDNs than solo practitioners.1
According to the 2012-2013 National Committee for Quality Assurance (NCQA) private health insurance plan rankings, half of the nation’s top 10 ranked plans (N = 474) are IDNs that provide insurance and employ the doctors who serve their clients.5,6 The rankings were published in the November 2012 issue of Consumer Reports, which states,“Unlike traditional, independent fee-for-service doctors and hospitals that make money by doing as many treatments and procedures as possible, whether needed or not, integrated plans prosper by keeping their customers healthy and avoiding wasteful care.”6
Source: Reprinted with permission from Kolodziej M, Hoverman R, Garey JS, et al. Benchmarks for value in cancer care: an analysis of a large commercial population. J Oncol Pract. 2011;7:301-306.
In the United States, substandard, heterogeneous, and excessive cancer care adversely affects a number of important short- and long-term outcomes including survival, quality of life, and cost.7,8 The complex and multidisciplinary nature of cancer care makes it prone to system failures, such as inadequate hand-offs, poor communication, and lack of accountability between providers. 9,10 Additionally, the cost of cancer treatments— especially medical oncology and specialty pharmacy drugs—is notoriously high. Hence, strategies to promote their cost-effective use have become key elements of cost-reduction efforts (Figure 1).11
In the 2012 market intelligence report, Academic Cancer Centers: Trends Impacting Key Account Management, Inside Oncology, LLC, predicted that by 2016, the majority of patients with cancer will be treated at IDNs and cancer institutions (Figure 2).12 Factors contributing to this trend include Medicare reimbursement rate reductions for community practices, loosened 340B drug pricing qualification criteria, and pressure to meet new quality and performance requirements of the Centers for Medicare & Medicaid Services (CMS).13 “CMS has put in quality programs that are really stimulating and motivating people to become more aware of quality of care and integrating care,” stated David Guy, managing partner at Inside Oncology.Well-established cancer centers have been delivering integrated cancer care for years. Most of them offer patient care teams comprising a range of specialists, as well as a breadth of services at a single location. In this setting, however, care is generally limited to the cancer episode, not prediagnosis or posttreatment. Primary care of survivors commonly reverts back to a primary care physician who is not affiliated with the cancer care center. However, many cancer centers have begun to take a more proactive role in survivor care as its importance has gained recognition.8,14
Site-of-care data from 2006 to 2010 sourced from the 2011 Drug Trend Report: The Express Scripts Research & New Solutions Lab. Projected site-of-care data from 2011 to 2015 generated by Inside Oncology, LLC.
IDN indicates integrated delivery network.
Source: Reprinted with permission from Inside Oncology. Academic Cancer Centers: Trends Impacting Key Account Management; 2012. http://www.insideonc.com. Accessed October 10, 2012.
Perhaps the truest form of integrated cancer care is the type delivered by the large full-service IDNs at the top of the NCQA rankings. These institutions offer care that extends beyond cancer diagnosis and treatment to targeted detection, prevention, and survivorship care.5,15 This version of integrated care is in accordance with the Commission on Cancer’s (COC) Cancer Program Standards 2012: Ensuring Patient-Centered Care, which mandates care throughout the cancer continuum, from prevention through end-of-life care or survivorship.8 Cancer centers may provide prevention and screening services, but often these services are offered at the community level and not targeted to specific patients. These stand-alone interventions, while beneficial, may not be as effective overall as those delivered as part of an organized program integrated into comprehensive long-term patient encounters.16
Andrew L. Pecora, MD
In other models of integrated care delivery, community oncologists are banding together into statewide or regional conglomerates such as Regional Cancer Care Associates (RCCA) of New Jersey, formed in January 2012. According to RCCA president Andrew L. Pecora, MD, by the end of 2012, the group will provide care for about half of patients newly diagnosed with cancer in the state of New Jersey. Among the initiatives being implemented by the group are cost-conscious protocols, networkwide integration of electronic medical record (EMR) systems, real-time overall and progression-free survival tracking software, and survivorship care planning in collaboration with local primary care physicians. “If I was to do this as a single doctor in my individual practice, it might be interesting; if we are doing it in an entire state…we will move the needle,” said Pecora.
In another model aimed at community oncology, McKesson Specialty Health offers tools to support delivery of integrated cancer care by practices belonging to The US Oncology Network, which is one of the nation’s largest networks of community-based oncology physicians. “For more than 15 years our affiliated practices have been pulling together resources our patients need into a single building in the community setting,” said Matt Brow, vice president of public policy and reimbursement strategy for McKesson Specialty Health. Brow said it is important to distinguish this type of quality- and value-driven initiative by oncologists from the trend of hospital systems buying up everything in their vicinity. For radiation oncologist Gregory Patton, MD, practice president, Compass Oncology in Portland, Oregon, being part of The US Oncology Network has been beneficial in terms of the resources and skilled professionals it offers. “The strength of the network is that its leadership and initiatives evolve from the practices,” he commented.
J. Russell Hoverman, MD, PhD, medical director of managed care for The US Oncology Network, discussed the challenges of delivering truly integrated care in the community setting. “We have a lot of things in our network that would fit into IDN but they are not all in the same place,” said Hoverman. Moving forward toward integration that is more complete will require cooperation with groups outside of their network, platforms for communication, incentives, and perhaps, payment change. “We are continuously looking at models in which we could do all this; I think we all agree this is the direction we need to head.” He also discussed how he would like to form long-term relationships with payers, rather than 1- or 2-year relationships, so they can collaboratively learn from and build on existing pathways and integrated care processes.
J. Russell Hoverman, MD, PhD
Well-designed, integrated cancer care systems are positioned to provide the types of services increasingly being recognized as essential to good cancer care by performance monitoring groups like the COC.8 Proponents of healthcare systems that integrate care throughout a cancer patient’s life journey talk about the benefits of team care, quick response, accountability, research integration, and systematic implementation of medical evidence, as well as the facilitation of screening and early detection programs.17 Ultimately, the benefits of integration should improve survival outcomes for patients. Cancer care delivery organizations are beginning to look beyond surrogate quality indicators to primary health outcomes. Kaiser Permanente’s most recently reported 5-year cancer survival rates were higher than the national average—in some cases 10% higher—for nearly every disease state (see Figure 3 for melanoma survival rates).18 “It is not just that we have great oncologists, but also because we do a lot of screening, prevention, and proactive patient support,” said Joanne Schottinger, MD, assistant medical director for Quality at Kaiser Permanente in Southern California. “Our patients are with us an average of 17 years; these people do well not only because they saw us as a cancer patient, but also because of the care they received outside of that phase. Everything else that needs to be done is being supported. It is an integrated network that leads to results like that.”
SEER Survival & Stage Survival can be calculated by different methods for different purposes. The survival statistics presented here are based on relative survival, which measures the survival of cancer patients compared with the general population to estimate the effect of cancer. The overall 5-year relative survival for 2002-2008 from 18 SEER geographic areas was 91.2%. The 5-year relative survival by race and sex was 88.9% for white men, 93.4% for white women, 62.5% for black men, and 78.5% for black women (http://seer.cancer.gov/statfacts/html/melan.html#survival). KP indicates Kaiser Permeuante; SEER, Surveillance, Epidemiology and End Results.
Source: Reprinted with permission from Kaiser Permanente. Letter from the CEO, George Halvorson. Celebrating cancer care successes at Kaiser Permanente. July 6, 2012.
With a heavy focus on early detection, Kaiser Permanente has set an organizational goal of having the lowest number of stage 3 and 4 cancers in the country. Its fully integrated EMR system was customized to fit its oncology needs and features tools that make every single patient visit, for any purpose, an opportunity to deliver clinical prevention services or to schedule a screening. Through its organized colon cancer screening program, which includes mailed fecal screening kits, the number of colon cancers detected at the treatable stages of 0 or 1 has improved to 41%, which is a 28% increase. Likewise, the number of late-stage colon cancers detected has decreased by 32% to just 13%. This work extends to other cancers as well (eg, breast and cervical), in which similar results have been garnered. According to Schottinger, they also attribute positive outcomes to robust prevention programs that focus on smoking cessation, alcohol use reduction, and overall wellness.
Through their EMR systems, IDNs share standardized point-of-care decision support, protocols, and patient information among all healthcare personnel within a network. “Being within an organized IDN offers opportunity for better care for patients and better communication through EMRs. These systems are organized so that providers can manage cases together,” said Guy. New health information technologies will allow organizations such as RCCA to share patient electronic health information across multiple disparate EMR platforms, avoiding the need for groups who have already made an investment in an EMR system to make changes.
EMRs have contributed greatly to standardization of cancer care across large provider networks through incorporation of continuously updated evidence-based treatment pathways. The US Oncology Network, a pioneer in this area, has published studies documenting maintained outcomes with improved practice standardization and reduced costs through the use of cost-conscious pathways that are disseminated network-wide via their proprietary electronic health record system.19,20
IDNs that use EMRs in conjunction with a team-based approach have also been able to enhance quality assurance and reduce chemotherapy-related error rates. Oncology pharmacists at Kaiser Permanente who monitor and manage patient safety have prevented 99.7% of patients with poor renal function from getting worse and 95.9% of patients on chemotherapy from developing anemia.
Furthermore, EMRs have advanced the power of clinical research programs within the IDNs. Hornbrook explained that the benefits have been tremendous in terms of increases in the availability, accessibility, and amount of data, as well as reduced workload (eg, chart abstractions). “We can do translational research out of (our EMRs),” said Schottinger. “That is really an exciting part for us…we get to look at how real people are responding to these regimens in the real world and build in the support that they need.” IDNs are capable of rapidly disseminating and deploying not only their own research-based safety responses, but also any externally issued medication or device safety alerts.
Joanne Schottinger, MD
Nonetheless, not all efforts at integrated health delivery are going to be effective. As discussed in a recent report by the US Government Accountability Office, the delivery of high-quality care must be the mission at the outset.1 At this point, clear documentation associating cost and quality outcomes with IDN-provided care is not available.21 The variations in the extent of clinical and financial integration of existing IDNs make evaluation, comparison, and metaanalyses difficult. “The field is still in its infancy in terms of measuring what integrated care is, what it should be, and what expectations should be,” said Hoverman.
Growing evidence suggests that consolidation of healthcare providers and hospitals in a market opens the door for the resulting health system to charge payers more for their services and reduces market pressure to provide patients with value-based, high-quality care.21-23 “When cancer doctors are employed by hospitals, costs go up in spades,” said Brow. He based this statement on reports prepared by healthcare consulting firms Avalere Health and Milliman that analyze site-of-service—related costs of cancer care.24,25 “The bigger a health system gets, the more leverage it has against the payer, the more indispensable it is to the payer,” said Brow.
Hospital systems argue that the higher reimbursement rates they receive for delivering chemotherapy are offset by other services they provide that are not available at private oncology practices, and by the fact that they are required to care for larger numbers of uninsured and underinsured patients. On the other hand, said Guy, the current fee-for-service model also incentivizes community oncologists to use the most expensive drugs to maximize reimbursement.
A 2010 report by AcademyHealth cited some of the potential clinical benefits and elimination of duplicate services that can result from integrating services for patients within a single organization.21 Nonetheless, some motivations for integration may be geared toward increasing volume and revenue, not cost containment or quality improvement.13,21 Evidence suggests that consolidation motivated by reasons other than efficiency will not garner efficiency.21