The “Hotspotters” Driving Up the Costs of Cancer Care
Once the biggest expenses in oncology are identified, these findings can be leveraged to reduce costs, said Matthew A. Manning, MD, Medical Director of Stereotactic Radiosurgery, Cone Health Cancer Center, Greensboro, NC, at the 2016 Association of Community Cancer Centers National Oncology Conference.
Becoming part of an accountable care organization (ACO) can control some of the high costs of cancer care by providing institutions with access to the Medicare claims data of its patients, thereby allowing them to determine what can be done in their own centers to reduce spending, Dr Manning said. The Cone Health Cancer Center is part of the Triad HealthCare Network, an ACO that saved $21.5 million in its first year.
ACOs are groups of doctors, hospitals, and other providers who collaborate to provide coordinated care to their Medicare patients.
“If doctors and hospitals benefit from savings, they are more like insurance companies,” Dr Manning said. “And presumably they can restructure the delivery of care, resulting in the identification of intuitive and nonintuitive opportunities for savings, as well as reduced redundancy,” he added.
Deep Dive into the Data
The Triad HealthCare Network developed clinical practice committees assigned to study costs and opportunities for savings, but the initial reaction from providers to cost-cutting measures was defensive, and many of them sought to protect their patient populations, Dr Manning said. So they had to let go of all the clinical assumptions and take a “deep dive” into the data to identify the “hotspotters.” These chronically ill individuals are defined as the highest-spending 5% of patients, and across healthcare, this 5% of patients accounts for nearly 50% of the healthcare expenditures.
The clinical practice committees started with 1 year of claims data involving 31,336 Medicare beneficiaries, 3942 of whom had a cancer diagnosis. The 3942 patients were divided into 3 cohorts—the low-cost cohort (55%) had annual claims totaling less than the ACO mean; the intermediate-cost cohort (29%) had claims totaling more than the ACO mean; and the hotspotters cohort (5%) incurred claims exceeding $50,000.
Initially 216 hotspotters were identified, but because the data could be skewed by cancer diagnoses that remain on patients’ records after their cancer was gone, they filtered it to include only the 70 patients who had 3 visits to a cancer center during the study period.
The committees sought to determine what made these 70 patients the hotspotters. Detailed medical characteristics of the group were recorded in a chart audit, revealing a relatively even distribution: no predominant tumor type, tumor stage, physician, or subspecialty stood out as most costly.
Compared with tumor registry diagnoses, patients with blood and bone marrow malignancies were 9.4 times more likely than patients without these malignancies to be hotspotters (P <.001), probably because of the high cost of drugs used for multiple myeloma or leukemia. In addition, patients with breast cancer were 50% more likely than patients without breast cancer to be hotspotters (P = .028).
Compared with data on tumor registry stage, patients with stage I disease were 20% as likely as patients without stage I disease to be hotspotters (P <.0003), and patients with stage IV disease were nearly twice as likely as patients without stage IV disease to be hotspotters (P = .015).
Because of multiple comorbidities, 90% of the hotspotters had emergency department visits, and 60% were hospitalized, with a median of 1 hospitalization. A high percentage of patients had renal failure (38%), congestive heart failure (33%), and chronic obstructive pulmonary disease (32%). Among the top 5 costs by category, chemotherapy was the top cost (33%) and the most common (87.1%) treatment modality, but it represented only 33% of the overall charges for patients with cancer.
“We looked at how some of these costs were generated, and how we could close some of the loopholes and reduce costs,” said Dr Manning. “We realized that one of the highest costs is the cost of death.”
Overall, 11% of the hotspotters died during the study year, and 34% died in the subsequent year. Patients who died were twice as likely as patients who did not die to have had an emergency department visit.
Reducing Emergency Department Admissions
Dr Manning suggested that there may be a way to recognize hotspotters in advance by identifying ≥3 comorbidities or by developing a comorbidity scoring system, although he warned that this methodology has not been validated.
He stressed the importance of communication between the oncology team and other departments to improve patient outcomes by keeping patients out of the emergency department. For example, a woman with breast cancer who needs cardiology services may have little support in her transition from oncology to cardiology, resulting in an avoidable emergency department or hospital visit, and maybe even death in the intensive care unit.
Palliative Care Program
Incorporating palliative care services can also reduce emergency department visits and increase savings. Dr Manning and his team measured the impact of a palliative care nurse practitioner in their brain and spine oncology clinic. The goals of integrating palliative care services into their clinic included the development of advanced directives, activation and documentation of the do not resuscitate orders, and the introduction of Medical Orders for Scope of Treatment forms. After 6 months of instituting the palliative care program, they saw a 33.3% enrollment in hospice care and an estimated cost-savings of $364,800.
Symptom Management Clinic
To further reduce emergency department utilization, the network implemented a standardized triage phone assessment system and established a symptom management clinic, in which an advanced practice provider helps patients manage their pain and other side effects of their cancer treatment. A year after the symptom management clinic was introduced, emergency department visits decreased by 24.5%.
Dr Manning also promotes the use of high-tech treatments and more integrated networks of care, including multisilo care teams and the involvement of primary care physicians for complex cases.
“Our data suggest it’s not the advanced technology that’s costing so much. It’s the way we’re managing patients, and we can make major strides in savings without cutting access to high-tech treatments,” he said. “Prove your cancer center is part of the solution to avoid being labeled part of the problem.”