Oncology Finds A Home In Patient-centered Medical Care

Oncology patients represent less than 1 percent of the patient population, but they consume 10 to 12 percent of overall medical costs, according to John D. Sprandio, MD, president of Consultants in Medical Oncology and Hematology (CMOH), a Philadelphia oncology practice which is recognized by the National Committee for Quality Assurance (NCQA) as a Level III Medical Home.

Studies are confirming the success of patient-centered medical homes (PCMHs) in primary care. Sprandio has modified that model and applied it to cancer patients, “a clinically vulnerable population requiring intensive outpatient management, with higher associated costs.”         “Nowhere can you see the type of savings offered by patient-centered medical homes than in cancer care, because there is so much fragmentation and failures of over-treatment,” says Sprandio. “This model fits very nicely into what healthcare reform is all about.”

Integrating with primary care

CMOH integrated its care with the primary care PCMH practices, with CMOH taking responsibility for coordinating and organizing all aspects of care related to the patient’s cancer. “Communication with the primary care team is essential,” Sprandio says. “We have developed coordination of care agreements with PCMH practices, essentially a responsibility matrix of what they should expect from us and vice versa.”

The model has numerous components, Sprandio says, including patient education, patient engagement, symptom management guidance and immediate access to care. Patient navigators direct and coordinate all aspects of patient care. CMOH serves as the point of first triage for any symptoms, especially when patients are undergoing chemotherapy or radiation therapy. During this critical time, the oncology team can provide direction and guidance more efficiently.
CMOH has been working on the same principles that were outlined by the American College of Physicians (ACP) defining PCMH neighbors. Sprandio has had conversations with ACP and specialty societies to develop a program compatible with their recommendations.

Most significantly, specialists can function as medical home neighbors to provide and manage services for patients who either have an overwhelming illness for a defined period of time or an overwhelming illness for an extended period of time. “Most hematology and oncology patients fall under those categories.”

Expanding the model

Other specialists could benefit from the PCMH model, Sprandio says, including cardiologists, nephrologists, rheumatologists and pulmonologists—those managing chronic illnesses. However, “the degree of clinical need and degree of cost is more pronounced in oncology. Thus, the need for care coordination is a little more pronounced.”

Adhering to this model has had a significant impact on CMOH’s resource utilization.

“Since 2007, we’ve documented a reduction in emergency department visits by 68 percent and admissions by 51 percent among our patients being actively treated.”
When CMOH applied for NCQA recognition in 2009, the practice applied all techniques that reduced utilization across its four sites. “Now, we admit patients half as frequently. It’s about providing improved access, improved information to our patients, improved coordination of care with primary care providers, while simultaneously addressing over-treatment and waste.”

Titles don’t matter

CEO of Elmhurst Clinic, the first recognized PCMH in Illinois, Donald Lurye, MD, MMM, says function is more important than form when applying the PCMH model to medical specialties.

“We are dealing here to some extent with semantics. The term ‘medical home’ still suffers from a lack of definitional clarity. A variety of organizations are attempting to place a stake in the ground here. Oncology patients have a great need for care coordination, enhanced communication and the wise use of resources. Well-run oncology programs provide all of that. Does that make the oncology program a medical home? We need to have highly coordinated, managed care executed efficiently and compassionately everywhere, including for allergies, neurology or oncology. To me, that should be our real thrust.”

Lurye recommends that any provider trying to emulate Sprandio and CMOH focus not on one particular recognition or certification program but rather on the results of the experience that his or her patients.  

“Whether one is ‘allowed’ to call this a medical home in some official sense is beside the point. To me, implementing the seven PCMH principles established by the Patient-Centered Primary Care Collaborative is far more important than what it’s called. While politicians continue to posture and debate, CMOH appears to be reforming healthcare in a meaningful and productive fashion.”

Future care

To survive economically, U.S. medical oncology practices need to develop and present a new value proposition to payers, Sprandio says. Historically, 85 percent of cancer care has been provided by independent practices like CMOH, but “that number is changing significantly” mostly due to a reimbursement system that currently does not provide economic support for the spectrum of services essential for the care of increasingly complex patients. An increasing number of oncology practices have changed their site of location to more expensive, hospital-based settings since 2009. Sprandio currently is expanding this model to additional practices through his practice transformation company, Oncology Management Services.
 
While many oncology-related vendors have focused on the price of chemotherapy drugs as a source of potential cost savings to payers and patients, those savings are finite. Chemotherapy accounts for 22 percent of the cost of cancer care, and adhering to a pathways program may save 3 to 5 percent of the total cost of cancer care. “The Oncology Patient-Centered Medical Home model has the potential to save an additional 10 percent of those costs by addressing and reducing avoidable complications of therapy, disease and comorbid conditions.”

Transforming to PCMH care delivery is the first step in driving desired patient- and payer-centric outcomes, Sprandio says. “Payment reform is necessary for oncology practices to achieve the goal of better care and health at reduced cost. Appropriate incentives are needed to drive provider accountability regarding proper staging and chemotherapy selection, decreased ER visits and hospital admissions and rational goals for therapy at every stage of treatment. All of these endpoints are measurable. Based on the results we have achieved in our practice, we know this represents a new value proposition for practices, patients and providers.”