Washington—Three years ago, when the population health chief of Lancaster General Health in Pennsylvania approached Nikolas Buescher, MHS, its executive director of cancer services, about looking into bundled payments for cancer care, Mr. Buescher thought there was no way the hospital could do it within five to 10 years. It was too complex, he said, and he thought there was zero market interest.
“I was wrong” about the interest, Mr. Buescher said during a presentation at the 2017 annual meeting of the Association of Community Cancer Centers (ACCC), pointing to the Oncology Care Model (OCM) sponsored by CMS. “But not about the complexity—that’s still proven to be a bit of a challenge for anybody who’s in the [OCM].”
The health system’s community-based cancer program, affiliated with the University of Pennsylvania Health System, is now one of about 200 groups participating in the OCM—a five-year effort that started in July 2016 to provide Medicare beneficiaries receiving chemotherapy with enhanced services, such as care coordination/navigation and treatment that adheres to national guidelines. Participating clinics must report data for 97% of their eligible patients. Mr. Buescher and Elizabeth Horenkamp, MD, the managing physician of Hematology/Oncology Medical Specialists, a nine-physician group within Penn Medicine Lancaster General Health, described how they incorporated OCM values into their practice.
OCM Values
The OCM has a number of requirements and quality measures, Dr. Horenkamp said, but they basically boil down to three big topics: improving patient engagement, documenting evidence-based standards, and trying to deliver care in the lowest-cost setting. “This is mom and apple pie,” she said. “It’s something you can sell to your physicians and do not just for the OCM but for our patients. That is what we started with.” Because the work is so data heavy, Mr. Buescher said, they allocated two full-time employees to abstracting quality measures from health records.
The next step was figuring out how to make changes and who was going to be responsible, Dr. Horenkamp said. Since 2010, her institution had been tying collection of some quality data to physician compensation. To avoid burning out any one group of professionals, the hospital pulled together a centerwide project team that included representatives from all departments: scheduling, nursing, operations, infusion, radiation therapy and data analysis. They considered input from all team members on the language used for shared decision-making documents for patients.
Inclusion Increases Compliance
One mistake, she said, was not including gynecologic oncology surgeons up front, thinking they were not as involved with chemotherapy. They have since been added and compliance from the group has skyrocketed, she said, adding, “Don’t forget anybody who’s going to be using this system. Have them at the table when making plans.”
The group, which began meeting in June 2015, still convenes every two weeks, Dr. Horenkamp said. They divided into teams to manage a few projects, and initially they had pizza parties where schedulers and information technology (IT) staff worked overtime listing the members of the care team in all cancer patients’ records. In other projects, nurses were responsible for revising anticancer (formerly called chemotherapy) education, and the administrative team worked to define the date of death because several OCM measures relate to what happens at the end of life. Lists from hospice or hospitals of which patients have died now go to all staff every month, and staff create condolence cards for families. “We’re not just doing data collection with this,” Dr. Horenkamp said. “We’re trying to do something meaningful for our patients.”
Medical assistants put together a tool detailing items that need to be addressed during every patient visit: staging; asking whether patients had had any hospitalization or major problems since the previous visit; asking about appetite and weight loss; and ensuring distress screening has occurred in the previous 30 days and that depression screening has occurred in the previous four months. Also included in the tool is a note that the caregiver should have at least a preliminary conversation about advanced care planning and should schedule a survivorship visit if a patient’s treatment care plan is curative in intent. Schedulers upped physician appointments from 15 to 20 minutes per patient to allow extra time to cover all these components.
In another project, physicians created a proposed treatment care plan for patients that explains in compassionate but clear language a patient’s stage; prognosis; treatment goals and expected response to treatment; expected quality of life on treatment; treatment plan, including how many sessions and how it will be administered; and who to call if there is a problem, with a list of support services available, such as a financial counselor or chaplain.
A Work in Progress
These new care pathways always are going to be a work in progress, according to Dr. Horenkamp. She said it’s important to ensure the involvement of all stakeholders up front as well as IT support. “If you can’t prove that you’re doing it, it’s not going to matter.”
One downside to the OCM is a lag in receiving financial and quality results from CMS, so full results from July to December 2016 won’t be available until February 2018, Mr. Buescher said. But his program isn’t content to sit back and wait. It has eight quality improvement teams tied to each of the top eight cancers working on various projects. One is depression screening, ensuring the hospital can prove that providers are appropriately identifying patients in need and that the patients who need a mental health counselor actually receive one. They also developed a performance dashboard that is shared with each care team each week. The dashboard reports on compliance with some of the OCM’s requirements/quality measures, including notes on what care teams need to do tomorrow and the next day to achieve the highest possible quality score and how the best provider in a particular group is performing. The program also instituted daily 15-minute huddles to discuss different measures and solicit ideas about how to improve care.
So is all the extra work worth it? It is, according to Mr. Buescher. “For us, it’s really not about the money,” he said. “We decided this was the right thing to do, and we’re doing this for all of our patients, not just for those covered by Medicare.” The health system recently signed an agreement with a local Blue Cross Blue Shield plan to do similar work for its beneficiaries.
“We’re all facing the reality of transitioning from fee-for-service to value-based reimbursement, and our colleagues who have participated in the OCM model have really been the pioneers from whom we can learn so much,” said Jennie Crews, MD, the immediate past president of the ACCC and the medical director of the Seattle Cancer Care Alliance Network and Research Integration. “The biggest lessons learned,” she said, are that this work, “really requires a culture shift in your whole oncology team” and that “to be successful, you have to gain consensus.” In addition, she said, these efforts take “more time than you may anticipate, and there is a lot required from IT and data analytics that most practices and most hospital-based programs probably are not currently equipped to handle.”
—Karen Blum
Mr. Buescher and Drs. Horenkamp and Crews reported no relevant financial relationships.