1. Butcher, Lola

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Nobody was talking about payment reform in oncology when Wilshire Medical Oncology Group began experimenting with some of the cancer care delivery and payment concepts that many payers and practices are now embracing.

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After gaining experience in a capitated contract, Wilshire Medical Oncology entered into one of the nation's first oncology medical home pilots with Anthem, one of the nation's largest insurers.


Linda Bosserman, MD, the practice's long-time president, is now a staff physician at City of Hope, but she continues to champion the goals of the oncology medical home: improving patient care while lowering the cost of that care.


I enjoyed speaking with Bosserman-who serves on the board of directors for the American Society of Clinical Oncology and on its Clinical Practice Committee and the Practice Guidelines Implementation Network-to discuss what she learned as a payment reform pioneer. And she gave me a sneak preview of the Cancer Care Business Summit, where she will discuss consumer-directed cancer care.


* How did your oncology medical home practice work and what did you learn from that experience?

"We started our work through a capitated contract with our largest HMO provider for half of our practice. We received capitation for drugs and hospital and office services and there was a carve-out for some of the high-cost drugs. So, way back in the 1990s, that made us sit down and think: If we have to practice medicine for a fixed cost to help protect our patients' access to healthcare, how could we look at each regimen, each pathway, and if there were choices among things that had an equal outcome and safety, we could choose the least expensive option, which would mean the patient also had the least expensive copay.


"And this was true for supportive care drugs, like nausea drugs, where oral drugs are often a fraction of the cost and equally effective for nausea control. We started looking at appropriate use of growth factors and medicines for bone metastasis and the specific regimens for cancer, especially the most common cancers. As we did that and our independent physician association (IPA) began to show we were a third to a half the cost of the other 12 practices that they managed, they also realized that we had minimal hospitalization costs because we were seeing our patients frequently, and they had very low emergency room and hospital use.


"I began to realize that the private payers were paying us to do more, whether or not it might be the most cost-effective for our patients. So I went to Anthem and said, 'We have the ability to really manage the patients, minimize hospital and emergency room use, and optimize regimens that can help the patients and the payers.' It took about five years and different medical directors because the payers really haven't had the information technology systems to monitor and oversee all of this. That was one of the biggest challenges.


"Ultimately, we launched the (oncology medical home) pilot in July 2010 and did it for three years. By that time, frequent meetings showed that our electronic medical record data was very accurate and up-to-date and could track hospitalizations, emergency room visits, the stage of the patient's disease, the treatments. The health plan would then do their claims roll-out, which could be a six- to nine-month delay and start looking at their benchmarks.


"It really was a pilot, but it showed that this data was collectable. We could be analyzing and managing the treatments and really learning in an ongoing way from each other. The payment was tricky because the S codes (used for billing) weren't really established at the time we launched, and they were not allowed to pay us differently than other providers. So they actually made a contract rate adjustment and we tracked to see if that worked as a kind of care management fee.


"That's where the pilot was left. Then, of course, Anthem launched their pathway program which has a care management fee for those patients who are on a pathway."


* Based on your experience, is the oncology medical home a standardized model-or is it something that must be customized to fit an individual practice? What are the essential elements of an oncology medical home?

"I think the second is true. We know the elements of it. You have to have full management of the patient. That means really having data for clinical and financial analytics. And you have to have policies and procedures in place to be able to collect the data in an integrated way, speak to patients, track their disease, any disease change or progression, their actual treatment, their response to treatment, their side effects, and any hospital and emergency room use, as well as their end-of-life care. We know those are the major elements of it.


"Not all [oncology medical home practices] have 24/7 access. There are many ways in different settings to meet the after-hours needs. For instance, our practice did not have extra hours, nor did we have nights and weekends, but we have chronic care clinics with our IPA, and we coordinated with specific urgent cares to be able to cost effectively evaluate patients after hours. And we could extend hours to some patients on a given day if the nurses were there early and a patient needed to be evaluated. So, I don't think there's one model, but the components of what's needed to really provide what is ideal care. Patients love it that you want to keep them healthier, that you know the cost of their care and are conscious of that when you make choices and help them make choices as they choose their comprehensive treatment plan."


* Healthcare payment reform seems to be headed in the direction of global payments, either capitated payments or bundled payments. How do you see this changing cancer care delivery? What are challenges of global payments for safety-net institutions?

"As for bundled payments, I am all for it. I think most people probably aren't. But I think we have to recognize there are risks and there are benefits. The benefits will be (that) it brings the cancer team together, usually under the medical oncology leadership because they are the long-term caregivers for the patients-not surgeons, not radiation oncologists-and it really asks, 'What does this patient need to have the optimum health outcome?'


"For instance, I do breast cancer. There is a chance of recurrence and you often have surgeons and radiation doctors seeing patients in long-term follow-up. That just goes away (in global payment models where medical oncologists manage patient care). We eliminated that completely. If I need a surgeon to see a patient, I work with them daily, I call them up, we get them right in. Same with radiation. But they are not the long-term monitors of patients because we need to be looking at their overall health outcome, including is their diabetes being managed, what is the cardiovascular risk, what about exercise, diet, nutrition? These things really affect long-term outcomes and lower their recurrence risk, as well as compliance with their medications.


"And then, you optimize the treatment options, discuss it with patients. There are certainly choices. A pathway is certainly narrowed down from a guideline, but there can be two or three choices. For instance, in early breast cancer, there are three common regimens in HER2 negative disease. We tend to use one for the lower-risk patients and one of the other two for those with higher risk. And I talk to my patients about those two choices. One has a lot more expensive growth factor use for an additional four cycles, and one doesn't but it requires more visits, it may be a little more effective, and it may have less toxicity. So I talk to the patient and let them participate in that decision-because the outcomes, as far as we know, are equal.


"These are the kinds of examples that a pathway doesn't have to come to one regimen. It often does for many diseases. Then, let's be realistic: for many diseases, we don't know the right treatment, especially as patients are living a lot longer. What is the second-, third-, or even fourth-line therapy for a patient doing really well and continuously responding? Certainly when patients are not responding, we know that palliative care and hospice are much more appropriate for some patients with advanced disease.


The upside of bundled payments is to be able to structure your team to really optimize the care and not waste patient visits on (unnecessary) testing. The risk is you have to know the cost to deliver the care. The biggest threat I see there is the Resource-Based Relative Value Scale (RBRVS) system, which is how most doctors are paid. If you start cutting out radiation visits, surgery visits, multiple consultations that you don't really need, then we still have to support appropriately those key clinicians we need to stay in business. And for medical oncologists, the RBRVS system is absolutely not measuring the cognitive time and effort to comprehensively oversee teams and take care of these patients.


"So the workload is skyrocketing, the documentation time is skyrocketing, and it's not recognized in our current payment system. We have more pilot work to do to get the details figured out.


"Our private practice took care of two safety net hospitals that both had populations larger than 15 states in the U.S.-San Bernardino and Riverside counties. And we loved the fixed payment. We negotiated payment to cover the physician and nurse practitioner and administrative services. We worked closely with the pharmacy to optimize every regimen in supportive care and in treatment to minimize the need for emergency room and hospitalization. You do have to have enough money to pay for the staff you need, and I think that's an ongoing challenge in making sure that we recognize the time and effort of the clinicians in taking care of these patients and keeping them as healthy as possible, making the best decisions and spending time on patient-centered decision making. So that's the risk, and that's the benefit."


* At the Cancer Care Business Summit, you will be on a panel discussing consumer-directed care delivery. What is that-and what should oncologists know about this topic?

"Consumers are having a much larger voice in health care. It's often where they know the least. I make the analogy with a car. When you want to buy a car, you can go online and investigate every car-from its dimensions to the marketing of it by different companies. You can go to Consumer Reports or numerous car sites and find out true comparison information, crash information, how efficient it is, what it's going to cost you long- and short-term. You can make a truly informed purchase decision based on your values.


"In health care that's almost impossible. We're bombarded by marketing by various centers and practices, but we don't have the clinical and financial outcome data to really know which group is providing better healthcare. Now we are getting this [type of information] for orthopedic procedures, which have very well-defined episodes. But patients need to know, for my type of cancer, and my subtype, and my health, and my comorbidities, what are the best treatment options? What will it cost me? What side effects am I going to have? What are the trade-offs on different options?


"In addition, patients don't want to come and wait for an hour. As much as we try to run our clinics on time, in cancer, people come in with recurrences, with new problems, with complications. It's very hard to staff and schedule perfectly for that. So how do we do more e-visits or televisits or supportive care conferences, especially as family members get involved? How do we do [online visits] with patients and their family when they really want to stop and discuss information?


"Consumers are saying, 'Hey, we want real-time, personal care. We want information. We want to interact with our clinicians pretty much real-time and at the site that's most convenient. And that's not always at the office.'


"So we have to really re-think technology and how we can better serve patients, and I think innovation is going to be really exciting."


iPad Extra!

For more details and specifics, listen to a podcast of the full interview with Dr. Bosserman on the iPad edition of this issue.

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