An oncology practice's patient-centered medical home uses a phone-based, nurse-operated triage model to direct 80% of callers to a solution without physician involvement and without hospitalization.
Re-organization of physician oncology practices "is not what's needed" to improve quality of cancer care in this country, says Philadelphia oncologist John Sprandio.
"It's organization that's needed, because there is no organization now. You would be shocked; the consumer would be shocked, and the physicians know what I'm talking about," he says.
Throughout the country, cancer patients largely don't know what to do when they develop potentially serious chemotherapy complications like diarrhea, fever, or dehydration, he says. They end up going to the emergency department, and sometimes they get admitted for problems that have gotten out of control.
John Sprandio, MD |
According to a 2010 report from Milliman, 22% of cancer patients get chemotherapy at a cost of about $111,000 a year, about four times the cost of cancer patients not getting chemo. That's in part because for every 1,000 patients receiving chemo, 929 have an emergency room visit, and 378 are admitted to the hospital.
It doesn't have to be that way, insists Sprandio, the chief physician of Consultants in Medical Oncology and Hematology, a nine-physician practice with about 8,000 patients. Many of these patients could be better managed at home.
That's why CMOH developed an oncology patient-centered medical home, a model that incorporates special triage clinics. Clinicians encourage patients to call at any time of the day or night as soon as they notice any cancer- or treatment-related problem.
CMOH's data demonstrates that this way is better for patients, for doctors, and for costs.
The practice's three clinics connect callers to well-trained, experienced oncology nurses who have at their fingertips a 25-algorithm decision pathway that directs 80% of callers to a solution without needing to get a doctor to resolve the issue, and without hospitalization Sprandio says.
CMOH's model is also one of the projects used by the Centers for Medicare & Medicaid Services to justify its launch of the Oncology Care Model next year.
CMS Announces Bundled Care Payments for Oncology
The episode-based model incentivizes qualifying cancer doctors with monthly payments per Medicare beneficiary undergoing chemotherapy to reduce hospital and pharmacy costs, in part through better care coordination. The model was developed for CMS with help from the Brookings Institution.
Sprandio provided these details about CMOH's results:
- The number of emergency department visits per year for each patient receiving chemotherapy dropped dramatically. For every five patients who had to go to the ED because of a chemo complication in 2004, only one had to go in 2013.
- Hospital admissions for chemotherapy patients have been reduced by half, between 2007 and 2013.
- The number of patients who phone in when they have problems has increased from 74% in 2006 to 84% in 2013.
- The model reduces the need for staff support, from 8.3 per staff oncologist in 2007 to 5.6 in 2013, with a corresponding 14% decrease in salary overhead.
Sprandio extrapolates savings from his model to between 6.6% and 12.7% for payers over what they would otherwise incur.
Over the years, he says, commercial insurers figured out that this model could save them money and drive quality too. To date, 48% of Sprandio's patients are covered by alternative structures that pay for triage care.
If all cancer patients were managed by this PCMH model, billions could be saved in reduced costs when exacerbation of chemotherapy complications are avoided, and happier, perhaps healthier, patients survive cancer.
And for those with poorer prognosis, "we've also increased hospice enrollment and the number of days on hospice, and we've driven an appropriate reduction in the use of chemotherapy during a person's final 14 to 28 days of life."
Call Support is Key
The key to the system is that patients must call in, and they must get good service when they do, Sprandio says.
"If they have to wait 45 minutes for a call back, then regurgitate their story to someone, who then has to regurgitate details to an oncologist, who then calls back the patient an hour and a half later, those patients aren't going to call again." They're going to the emergency department.
Sprandio says he's been a "lightning rod" critic of the way cancer care happens in this country.
"I don't think physicians understand they must change their behavior. They have to reassign the roles for staff members and streamline the way data is collected and presented, and the way they respond to that data" so they can see what is actually happening to their patients during and after treatment.
Sprandio gives an example with a hypothetical patient.
Before the model, she would name five issues she was having during an office visit. "I would focus on three, and address them well, but forget about the other two because there was no systematized data collection template like we've now developed. One of those two symptoms I overlooked might have been morning indigestion that over the next day and a half resulted in nausea and dehydration and hospitalization four days later."
A Strategy of Prevention
With the current model, an electronic template allows all issues to be addressed. "Physicians need to embrace the complexity of what we do with these very clinically-at-risk patients," Sprandio says.
Another trick is to reduce variation in nausea treatment. A few years ago, half the doctors in Sprandio's practice were giving patients expensive doses of Zofran indicated to treat nausea occurring on the same day as chemo. But Zofran causes complications. Older patients may develop severe constipation and low potassium, resulting in dehydration, a trip to the emergency department, and sometimes an admission.
The practice discovered also that a lot of patients didn't get nausea until 40 hours after chemotherapy and that a big cause of nausea was actually stomach irritation from excessive production of acid.
"Three of us started putting patients on a medication that reduced stomach acid, and guess what?
"We've reduced the number of oral Zofran prescriptions from 260 to 32 over a six-month period. It was better because it prevented the problems in the first place."
Another strategy involves ways to better manage diarrhea by determining with more accuracy whether it's related to chemotherapy, or something else, like a norovirus at home. "We standardized it so we weren't all doing something different."
Sprandio's company, Oncology Management Services, helps practices standardize symptom management. "We don't dictate the use of our algorithms, but we give examples, and practices develop their own in-house variations."
Although Sprandio is enthusiastic about the CMSs new payment model for chemotherapy patients, he says it will have to be tweaked.
He worries that some patients may be started on chemotherapy too soon by providers wanting to hasten the monthly payments from CMS. And with horrifying price tag of some chemotherapy drugs, he worries that providers who use them when they're appropriate will cut themselves out of shared savings.
Nevertheless, he says he will sign up for the program, hoping CMS will fix those flaws. "When this goes through, there will be another 38% of our patients included in an alternative payment methodology," and that means more resources to make the system work better for cancer patients suffering through chemotherapy.