It was about six years ago when Barbara McAneny, M.D., an oncologist/hematologist and then-practice manager at the Albuquerque-based New Mexico Cancer Center, was at an AMA (American Medical Association) meeting when a critical recognition about healthcare delivery was realized. It was McAneny who was learning at the time from her practice’s patients that being in the hospital is not only a “medical disaster, generally, due to what they end up with in terms of complications, bacteria, bed sores, and other problems, but it’s also a financial disaster and very disruptive to their lives,” she says.
McAneny also was learning that as an oncologist, any time a patient leaves the hospital, he or she is never as healthy as at the time of arrival. “So we decided in our practice that we wanted to figure out how to keep patients out of the hospital by intervening with the problems of cancer and its treatment earlier in the process. I discovered that this would decrease our hospitalizations, which also meant saving our patients and the health plans a lot of money,” McAneny says.
This was also about the time when the Center for Medicare & Medicaid Innovation (CMMI) was getting off the ground, established under the Obama administration to allow Medicare and Medicaid programs to test models that improve care, lower costs, and better align payment systems to support patient-centered practices. At the AMA meeting, one doctor spoke up about how he was getting frustrated because his hospital’s innovation models were not saving money as expected. McAneny, who was just recently elected president-elect of the AMA, recalled that she told the doctor at the time, “The key is to keep people out of the hospital, so I am not surprised you’re not saving money since a lot of your models are hospital-based. Then I showed him the data from our practice,” she says.
Barbara McAneny, M.D.
Indeed, at the New Mexico Cancer Center, the most important factor to its business success has been its triage pathways. McAneny explains that in most practices, the current triage process is that when patients pick up the phone to call their doctor, they get a recording saying, “If this is a medical emergency, hang up and dial 911.” But McAneny says that this is the first mistake. “Everyone who is calling thinks they have an emergency,” she says. The second mistake, she continues, is that often in a practice’s triage, the nurse who is handling triage that day has no decision support. “Someone calls in and says he or she has a fever, so the nurse will look at the doctor’s schedule, and it’s packed with patient appointments, so the patient is told to go to the ER. And this happens thousands of times a day throughout the U.S. They don’t have the infrastructure setup to manage this as is.”
But what McAneny did was model these triage pathways after a system the EMS uses to train non-medical personnel to send equipment and machinery to the right address with high degrees of accuracy. She notes that the pathways in her practice started with patients’ complaints in the manner in which they would actually address them.
Patients would never call up and say “I have Stage 3B lung cancer.’ They say ‘I have a cough and a fever.’ So we started from the patients’ symptoms, and [then] it is decision support for the nurses [or first-responder phone operators] who are on the phone, backed up by a change in how the practice works. There are mid-level providers, nurse practitioners, and PAs who have an open schedule for that day, so that when patients call and say they have a fever, the person on the triage works down the path to see what the best way to manage them is.”
In essence, the nurses are guided through step-by-step clinical decision making as they discuss and assess a wide variety of patient issues, McAneny explains. She adds, “When people are sick they need someone else to manage their own healthcare; they are too busy being sick to figure out what to do next. Our theory behind this is to make it so that all the patient has to do is show up.”
In 2012, the CMMI awarded a $19.8 million grant to the Innovative Oncology Business Solutions (IOBS), a corporation created by McAneny for the purposes of administering this grant. The money was for the development of a Community Oncology Medical Home model (called COME HOME), and the implementation of that model in seven practices across the country. At its heart, the model is a professional infrastructure built around the patient and their support system and available at the time of greatest need. As such, its target population is newly diagnosed or relapsed Medicare, Medicaid and commercially insured patients seeking oncology care at one of the seven participating clinics.
The protocols have already produced noteworthy results among the seven practices participating in the COME HOME program, who have collectively reduced their overall cost of care by 7.2 percent, driven by decreases in inpatient hospital admissions (12.5 percent), 30-day hospital readmissions (11.7 percent), and ER visits (6.6 percent). In addition, the COME HOME program was recently expanded through a collaboration with the American Society of Clinical Oncology (ASCO) that will see its tools replicated and expanded across the U.S., officials note.