The Oncology Medical Home: Embodiment of the American Pioneering Spirit

Dallas, TX—The American Pioneer Spirit is still alive today. At the 2012 Cancer Center Business Summit, attendees enjoyed the chance to walk through the challenges and possibilities of an emerging model in cancer care that is quickly becoming a buzzword for change—the oncology medical home.

Among the leading pioneers in the world of the oncology medical home are Linda D. Bosserman, MD, President of Wilshire Oncology Medical Group, La Verne, CA, and John D. Sprandio, MD, President of Consultants in Medical Oncology & Hematology and Chairman of Oncology Management Services, Drexel Hill, PA.

Susan Tofani, MS, Director of Network and Payer Relations, Oncology Management Services, joined Dr Sprandio and Dr Bosserman in discussing their experiences involved in establishing the first oncology medical homes in the country. They offered updates for those involved in oncology on their efforts and on the progress of their initiatives.

Wilshire Oncology Medical Home
Dr Bosserman said that her and her oncology team’s exploring the oncology medical home was driven by the need to look, in collaboration with payers, at how oncology could be paid differently for various outcomes. An oncology medical home absolutely requires a partnership between the payers, providers, and patients, she said.

The concept of the oncology medical home can be defined as patient care that delivers “cost-effective care on evidence-based guidelines, with warranted variations for fully engaged patients, given whenever patients need it, by experienced clinician teams led by doctors coordinating care with others, inside and outside of the clinic, that can lower costs and improve health outcomes for cancer care from prevention to end of life.”

One key difference for providers transitioning from a more traditional oncology practice setting to the world of an oncology medical home is that their practice and their focus is now patient-centric rather than physician- or clinic-centric. To accomplish this takes a fully engaged and reengineered oncology practice that involves the entire team.
Dr Bosserman’s group reengineered their practice to build a team of caregivers that is focused on patients’ needs and preferences in a cost-effective manner. The elements of that reengineering focus on a patient-centric oncology practice include:

  • The patient’s disease, health, and preferences
  • Engaged practice coordination of all care
  • Active partnership between providers and payers
  • Outcome validation and outcome reporting
  • Value-based quality and cost
  • Comprehensive care management and coordination
  • Comprehensive care plan and coordination.

The Wilshire oncology medical home was the culmination of approximately 4 years of development with Anthem BlueCross BlueShield of California. After much discussion regarding practice and plan capabilities, data collection, comparators, and potential models, an initial pilot was launched in mid-2011. The first year was focused on identifying trackable data elements and aligning payment modeling.

Anthem and Dr Bosserman’s group learned that their organizations could focus on the following trackable elements and components of patient care:

  • Therapies: cost-effectiveness by stage, tumor features, evidence-based guidelines, generics, consistency with age, comorbidities, and warranted variations, in­cluding clinical trials
  • Supportive care that is cost-effective for nausea and vomiting, white and red blood cell growth factors, and bone metastasis
  • Initial and interval symptom management to relieve suffering, lower complication costs, tackle the common toxicities of therapy (ie, pain, nausea and vomiting, diarrhea, constipation, dehydration, infections, and blood clots), and to encourage therapy compliance and adherence
  • Optimize the site of care: office, extended office, urgent care versus emergency department, hospital, and tertiary care
  • End-of-life care.

The Wilshire oncology medical home partnership is now able to track care progress through the following sets of data-based validated reports that form the basis for the payments:

  1. Patients under care: achievable benchmarks of care (ABC) preferred provider organization population
  2. Patients receiving therapy
    – Therapy and supportive care: choice, goal, line, and warranted variations
    – Guideline compliance and warranted variations
  3. Interval care tracking with
    – Extended office, urgent care versus emergency department, and hospital
    – Cancer therapy and cancer symptoms versus others
  4. End-of-life care
    – Advanced-care directives
    – Palliative care only and hospice care tracking
    – Site of care tracking
  5. Quality measures: American Society of Clinical Oncology, meaningful use, ABC
  6. Benchmarking.

One key element to executing the program was the issuance of an urgent care card to patients that contained explicit information about who and when to call with questions during their care. Prominently displayed on the card is, “First call your oncology care physician,” along with the appropriate contact information, which sums up the focus on the oncology medical home concept: the physician is the primary point of contact and serves as the hub through which all care is delivered.

Some of the information learned at the end of the first year of the oncology medical home initiative with Anthem BlueCross BlueShield, said Dr Bosserman, included the key steps for the group and the payer that reflect the ongoing commitment, related to care and reporting, data exchange and analytics, and data export and accountability. They have identified opportunities for continued optimization of care—related to transfusions, generic drugs, and after-hours care—as well as plans to enhance the program in years 2 and 3 through benchmarking, cost reviews, and expanded patient care opportunities.

Dr Bosserman noted that her group and Anthem have learned that a patient-centered, value-based cancer program can benefit an accountable care organization and can provide value and positive care enhancement by leveraging delivery systems, costs, quality, and a strong payer partnership.

Oncology Patient-Centered Medical Home
Dr Sprandio provided an update on the initiatives of his Consultants in Medical Oncology Group related to oncology medical homes on the East Coast. He noted that “every physician who treats a patient is a patient-centered medical home,” and that these programs provide a way to formalize the process and hopefully get paid for the care that is being provided.

Dr Sprandio added that “only those giving the care can improve it.” And a part of that care improvement process will, of necessity, include:

  • Reengineering the processes of care, including information tech­nology and support
  • Developing a patient-centric ap­proach
  • Fixing accountability at the patient-physician locus
  • Minimizing clinically irrelevant physician activity
  • Communication, coordination, access, and engagement between patients and payers
  • Demonstration of value through measured outcomes and costs
  • Improving quality of care and reducing utilization (ie, costs).

In addition, Dr Sprandio has developed a branded oncology medical home model called the Oncology Patient Centered Medical Home (OPCMH) and has founded Oncology Management Services, Inc, to help practices that are interested in using his OPCMH model develop oncology medical homes in their markets.

Oncology Management Services has partnered with International Oncology Solutions to bring the OPCMH concept to medical oncology practices in southeastern Pennsylvania. The OPCMH model in­corporates:

  • Clinical and business methodologies for practice and patient efficiencies in the community oncology practice
  • The organizational construct and use of the oncology medical home as a neighbor to the primary care patient-centered medical home
  • Establishment of the model as a bridge for oncologists to use for other care initiatives, including accountable care organizations, clinically integrated models, etc
  • Establishment of a platform for pricing oncology in a bundled or episode-of-care payment.

Dr Sprandio provided the updated results and outcomes from the contract his group holds with Keystone Mercy Health Plan, noting that they have ongoing conversations with other key payers in the area to support his medical home model.

Further expansions of the model and concept are being explored with state oncology societies and practices across southeastern Pennsylvania. Dr Sprandio is also engaged in discussions with the National Committee for Quality Assurance and the American College of Physicians regarding inclusion of the OPCMH model in their specialty practice recognition programs.

Working in association with Dr Sprandio, Ms Tofani discussed the basic elements relevant to building
an oncology medical home. According to Ms Tofani, implementing an oncology medical home requires:

  • Fully implement an oncology-specific electronic medical record system
  • Define clinical and financial goals
  • Secure buy-in from physicians via efficiencies
  • Engage payers and commit to new value proposition
  • Standardize processes of care
  • Overlay a clinical decision support system
  • Improve clinical communication and coordination
  • Integrate horizontally and vertically
  • Commit to continuous process improvement.

Accountable Care Organizations
All 3 panelists agreed with the core value proposition that oncology patient-centered medical homes are in fact accountable care organizations. Dr Bosserman noted that sometimes it is a challenge to discuss these concepts with payers early in certain markets, but such discussions are crucial to establishing a medical home in oncology.

With a nod to the financial challenges that are facing community oncology practices of all sizes across the country, Dr Bosserman said, “If we can’t get payers to talk to us and look at these innovative systems in the next year, we may not be here to negotiate with them in 12 months.”

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