North Star Lodge of Yakima, Washington, found that making the Oncology Care Model work involved solving a long series of problems.
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.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.
“Too many of our patients still have financial problems that can affect outcomes. Some of them cannot even afford to run their air conditioners, so they turn them off during our very hot summers and put severe stress on their already weakened bodies,” said Tricia Sinek, care coordinator for Memorial. “That said, the expansion of the Medicaid program and the expansion of our financial counseling services have put most of our vulnerable patients in a much more secure place financially, and we expect that to improve outcomes by freeing them to concentrate on getting better rather than paying the bills.”
Sinek notes that North Star offers more financial support than many patients realize, including emergency funds for heat and air-conditioning. Therefore, the practice is working to further improve its financial counseling and convince patients in need to accept valuable help.
North Star’s participation in the OCM only passed the 1-year mark at the end of June, so it’s far too early to know whether the initiative has affected long-term outcomes. The federal government used claims data to tally the initial effect on short-term metrics such as ED usage and patient hospitalization, and those figures show that although North Star lags OCM program averages on some metrics, it beats them in others, offering some evidence that the OCM model can work in a rural setting.
It is likewise too early to evaluate the OCM program’s effect on the finances at North Star. In addition to giving practices the opportunity to share in any money saved from reduced ED or hospital usage, the program pays North Star care management fees amounting to an extra $160 per month for each Medicare and Medicaid patient receiving chemotherapy. In exchange, North Star provides guideline-based treatments, patient navigators, 24-7 patient access, explicit patient care plans, enhanced data reporting, and other extras. The extra expenditures slightly exceeded the extra revenues during the program’s first year, but the efficiency that comes with experience may well change that in year 2.The impact of the Medicaid expansion upon North Star’s finances is far clearer. Increased coverage has reduced the need for charity care and, therefore, the need for limited state funds and private donors to cover such expenses after the fact. The more predictable stream of payments has, in turn, made it easier for North Star to budget for initiatives designed to improve care.
“We are currently beginning a major push to identify which groups in our community continue to suffer below-average outcomes, whether that is because they are medically underserved or [for] some other reason. Once we have identified those groups, we will design programs with an eye toward closing the gaps,” Sinek said. “For example, we do know already that we have a high tobacco use rate in this community and a similarly high rate of lung cancer. We plan to launch a major public health initiative that will focus on both reducing tobacco use and getting more people screened more frequently for tobacco-related cancers.”
The dramatic nationwide reduction in tobacco use over the past half century demonstrates that public health campaigns can work in the long run; changing behavior is never easy, however, and it may be harder in the Yakima area, where health-related metrics lag below the averages for Washington state.
Norris L. Washington and the ACA’s Medicaid expansion. www.healthinsurance. org/washington-medicaid. HealthInsurance.org. Published September 26, 2016. Accessed August 28, 2017.
“Medical information is complicated, so communicating it clearly to members of the general public is difficult under the best of circumstances, and you’re almost never talking to cancer patients in the best of circumstances,” Talcott said. “The disease is terrifying, and the emotion clouds comprehension, as does chemotherapy when you get into the treatment phase. You think you are saying one thing very distinctly, and patients can easily end up hearing something else.”