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Five years ago, Capital BlueCross asked community oncology practices in its network what kind of reimbursement model they would like to try as they worked to stay financially viable and independent.
John Sprandio, MD
Five years ago, Capital BlueCross, a health insurer in Pennsylvania, asked community oncology practices in its network what kind of reimbursement model they would like to try as they worked to stay financially viable and independent. After rejecting the idea of a clinical pathways program, the practices expressed interest in specialty medical homes, particularly the patient-centered model pioneered by John Sprandio, MD, in the Philadelphia area.
Sprandio spent years standardizing care, streamlining workflows, and improving the electronic medical record (EMR) system at his oncology practice, resulting in fewer hospitalizations and substantial cost savings. Starting in 2015, the insurance company asked Sprandio and his consulting firm, Oncology Management Services (OMS), to bring his model to 4 of its network practices.
In July, Capital BlueCross received the first batch of practice-performance data, covering the second half of 2016. Thanks to reductions in emergency department visits and hospital admissions, the financial results were “really positive,” said Denise Harr, MD, senior medical director of Capital BlueCross. Patients’ total medical costs over 6 months were down 5.2% compared with a previous baseline period, and pharmacy costs dropped 13.9%. Even with incentive payments that practices received along the way, the effort has already achieved savings, Harr said. Measures of care quality did not improve as much, but both the insurer and the practices expect to see more positive results in the first half of 2017. “I’m hearing the practices say that this increased support they’ve received from John Sprandio and his team really helped them to feel like they’re impacting our patients’ lives in a different way and a better way,” Harr said. “They’re doing something different, and it’s measurable.”
Two of the 4 practices are in CMS’ Oncology Care Model (OCM), which was influenced by Sprandio’s work and resembles his model in many ways. Under his team’s guidance, the practices created or expanded phone triage systems to better manage patients’ symptoms, improved processes and technology for collecting and analyzing data, and made other changes required by the OCM. “We are very thankful for the experience of being in the Capital BlueCross pilot, because we really feel it prepared us to be successful in the OCM,” said Azlynn Swartz, MHA, BSN, RN, OCN, executive director of Andrews and Patel Hematology/ Oncology in Camp Hill, Pennsylvania. “They really worked with us to make the changes we needed to make. Other practices, I think, are struggling. They’re where we were 2 years ago.”
The pilot kicked off in July 2015, with the practices filling out questionnaires to guide Sprandio’s recommendations, Harr said. His team held webinars, visited sites to observe workflows, developed individualized blueprints, established timetables, and suggested technology improvements. To help fund infrastructure upgrades and hiring, Capital BlueCross reimbursed the practices for meeting a series of participation milestones over the program’s first year.
In one part of the transformation process, the practices developed symptom-management maps to guide nurses’ phone conversations with patients experiencing adverse effects from drugs. Swartz said OMS provided a template for decision-making paths, which a clinical group at Andrews and Patel modified based on their beliefs about the best responses. This standardization leads to individualized management of patient issues, avoiding automatic emergency department visits and unnecessary interruption of busy physicians, she said.
“What we’re working on now is using that phone call as a launching point for continued proactive telephone calls to the patient to say, ‘We talked about this yesterday. How are you today?’” Swartz said. “We’ve come up with a way to utilize the EMR to form a queue that a nurse will look at each day and make outbound calls based on people who have had recent symptoms.”
The practice staff is also focusing on improving the often-complicated task of tracking different aspects of patient care to make sure no steps are missed. For example, Andrews and Patel wanted to track whether it had received radiology reports doctors had ordered. The EMR did not easily allow that, so the practice built in a button that would attach a radiology test to a patient’s chart, Swartz said. Now a report can be run to show all the tests received— provided staffers didn’t forget to click the button.
“We’re tracking what percentage [of the tests] are back in the time frame that we think makes sense, and then we have a benchmark: what percent do we want to be at? Here’s our goal, and can we do better the next month?” she said. “We’re running reports like that for many things that we’re doing, and that’s taking a lot of time, but it helps us to see where our gaps in care are. I do think it’s actually helping us be better.”
Such processes are laborious in large part because the EMR cannot perform them automatically. Swartz said the OMS consultants were disappointed in the limitations and said they had underestimated the importance of a customized EMR, such as the IRIS system Sprandio developed for his practice over many years. Sprandio said the obstacles he encountered at the Harrisburg-area providers resemble those he has wrestled with at other practices that are building oncology medical homes.
“The challenges were purely related to the deficiencies in their EMR product. All the practices that we’ve worked with have realized efficiencies. The degree of physician efficiencies was only limited by the IT systems that they were saddled with,” he said. “We ended up making the best of an equally bad situation with whatever EMR vendor that they had.”
In July 2016, Capital BlueCross launched the performance portion of the pilot. It began paying monthly care-management fees for each patient and using claims data to compare the practices’ total cost of care trend with that of nonparticipating providers. This summer, using results from the second half of last year, the payer adjusted each practice’s fee schedule to incorporate performance-based incentives, Harr said. Adjustments will be made every 6 months based on the latest batch of available data.
Swartz said Andrews and Patel has noticeably bulked up its staff and invested in more software and services. In addition to the incentives from Capital BlueCross, the practice receives Monthly Enhanced Oncology Services payments from CMS as part of the OCM. Those combined funds cover the ongoing costs of participating in the programs, but just barely, she said.
Swartz also said that, while her practice greatly appreciates the practice improvements and OCM preparation provided by Capital BlueCross, the pilot program does nothing to ease the administrative burden of managing prior authorizations and drug denials imposed by payers doing whatever they can to cut spending. She looks forward to a day when payers reward OCM practices with easier and more technologically advanced claims management, but she has so far seen no sign of such reforms, she said.
There is hope, however, of more sophisticated information management within some practices in the near future. Sprandio said McKesson Specialty Health and the US Oncology Network licensed OMS’s technology last year, and he’s working with the staff with the goal of introducing IRIS into their extensive practice network. “We would like nothing more than to be a part of a larger organization and scale this up, and really impact the lives of a lot of patients,” he said.
Sprandio is also connected to McKesson through the Vantage Cancer Care Network, an independent practice association in southeastern Pennsylvania that promotes value-based care by facilitating oncology medical homes and arranging risk contracts with payers. He serves as medical director of Vantage, which is owned by McKesson, and is on the executive committee of Tandigm Health, which pays primary care doctors to closely manage patients’ care with the goal of cutting costs. Vantage has a contract with Tandigm, which is owned by Independence Blue Cross and Davita Healthcare Partners.
The oncology medical home concept that Sprandio has been working to propagate, along with similar efforts around the country, will face a major test next year when the 192 OCM practices must decide whether to join the 2-sided risk version of the model. Few have expressed interest in taking that step, because the model will assess heavy financial penalties on providers that fail to meet cost-saving targets, possibly forcing them out of business.
According to Swartz, oncology administrators still don’t understand exactly how CMS will calculate performance scores and whether the data-collection process is robust enough to accurately portray everything a practice does. She’s also concerned about the feasibility of cutting costs year after year, as the OCM appears to require. “I’ll be surprised if we choose 2-sided risk,” she said. “It’s just scary.”
One of the very few oncologists who are bullish on participating in the 2-sided OCM is Sprandio. He acknowledged the concerns about how CMS will perform calculations but said the agency staff is working on those issues. “We’re positioned to strongly consider this and potentially do it, if in the final analysis it makes sense. I’m OK with taking risk as long as it’s an educated risk and there’s an understanding of the components,” he said. “CMS certainly anticipates there are going to be some practices participating. I’m anticipating we’ll be one of them.”