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.
It was recently announced that Integra Connect, a West Palm Beach, Fla.-based provider of technologies and services for value-based specialty care, would partner with IOBS to incorporate the COME HOME program triage pathways into its Oncology Care Model (OCM) and population health solutions. Oncology practice staff using Integra Connect solutions will now look to leverage IOBS’s set of protocols to provide “aggressive symptom management as part of their patient triage and care coordination workflows, then track and report on results via advanced analytic capabilities,” officials note.
McAneny says that when she first presented this model, the decision support provided for the nurses makes sure that the nurse on the phone is guided through all the different diagnoses possible, so the patients are delivered to the right site of service. For instance, she explains, some services should not be had at the oncology practice, but rather the ER. On the other hand, if the patient on the phone is a woman who has breast cancer in all of her ribs, has rib pain in the left side of her chest, and has already had three cardiac work-ups for left-sided chest pain, there’s no need to go back to the ER for the same thing. McAneny adds that this decision support also protects against medical liability. “We have 29,000 patients going through the triage pathways and we did not deliver anyone to the wrong site of service to where there was an adverse event,” she says.
The next phase, according to McAneny, a step that will “restructure how oncology care works,” will require an incredibly strong data analytics partner, she says, explaining that there are two kinds of healthcare risk—actuarial risk, referring to the people who walk into a practice outside of a provider’s control, and then the risk for a patient who has a set of clinical criteria, such as the type of cancer, what stage it is, what the genomics are, what the comorbidities are, and what the treatment plan is. “You can have a target directly attached to that patient for a risk corridor of what their cost ought to be. And then you can see if you can manage that patient well enough to beat that target. I call that transactional risk, because it is that transaction with that patient which we should be able to manage. I should be able to keep costs within a certain level for a given patient,” McAneny says.
However, she adds this can only happen if it’s known what those costs are, which means “I need to analyze a lot of patients who have that [same thing] so I can track it prospectively,” she says. “You need a way to manage all of this, and that means pulling the data. If you have a practice of 20 doctors, and one decides not to follow the clinical pathways and does something strange and expensive for a drug that wasn’t needed, for example, I need to know that very early so we can intervene. So you need a very strong data system that monitors how well people are compliant with the pathways that the doctors have set up to treat people,” she says. “And then you have to be able to look at outliers, and track if a patient with cancer has something else as well, so therefore that patient will be an outlier in that target corridor. I need a way to know that early and work with the payers to [determine] where a patient fits best. It has to be real-time data and it has to be fast, and practices can’t be paying big fees every time they need to look at the data.”
Becoming a MACRA APM?
Currently, IOBS COME HOME is referred to as a “medical home” rather than a “delivery model” since there isn’t a payment system attached to it. So right now, the medical home is NCQA (National Committee for Quality Assurance)-accredited, but as McAneny explains, “It needs a payment system to go with it because one of the flaws of a medical home is that we provide a lot more services for which there are no fees” attached, such as patient education and nurses talking on the phone. She adds that there is an opportunity cost of leaving an advanced practitioner, nurse practitioner, or PA with a blank schedule, despite the organization’s overhead costs continuing. “And the savings from this go to the payers who don’t have to pay for a hospitalization or an ER visit. So we need to attach that to a payment system.”
When McAneny had the CMMI grant, she was able to pay the practices for those personnel who you can’t bill for—the nurses on the phone, for instance. CMS then said it would embed the COME HOME pathways process as a way to create the savings, and will use its normal ACO (accountable care organization) upside/downside risk opportunities as the payment system on top of it.
But then, McAneny explains, CMS added in a $160/month payment for the nurses who were educating and spending time on the phone, a cost that McAneny’s team calculated should actually have been between $220 to $250 per-patient, per-month. “So they are giving $160, and that’s a problem since that doesn’t totally support [what we’re doing]. So if you don’t have another payer paying for it, that’s another cost.”
Indeed, the current CMS Oncology Care Model will award 15 points for practice improvement under MIPS (the Merit-based Incentive Payment System), just by participating. The COME HOME process already qualifies as that, and it would become an alternative payment model (APM) under MACRA (the Medicare Access and CHIP Reauthorization Act) if the provider accepts risk. “I don’t believe practices have accepted risk yet; sometime in 2018 people are supposed to decide if they can hit the targets CMS has set for spending and be able to accept risk or not,” says McAneny, who adds she “has great concerns for that.”
To this point, she points out that insurance companies “go under” if they don’t have reserves, and they are required to prove that they have reserves. But if practices go at actuarial risk like an insurance company does (for example, if they bet that 5 percent of their patients will be sick and expensive, and it turns out that it’s really 8 percent who are sick and expensive), they don’t have the reserves to cover that two-sided risk. “And that’s a practice-ending event,” says McAneny. “So asking a practice to pretend they are an insurance company without reserves won’t work.”