1. Holt, Chuck

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The Centers for Medicare and Medicaid Services (CMS) launched the Oncology Care Model (OCM) in 2016 as part of an effort to develop new payment and care delivery models for specialty practices. The CMS-funded OCM program aims to help oncology practices provide higher-quality, better-coordinated care at the same or lower cost to Medicare through practice transformation centered on reducing emergency department visits, hospitalizations, and patient admissions, while increasing satisfaction scores.

David M. Waterhouse,... - Click to enlarge in new windowDavid M. Waterhouse, MD, MPH and Molly Mendenhall, BSN, RN. MODEL PROVIDERS: David M. Waterhouse, MD, MPH, medical oncologist and Co-Chair of the Clinical Research Department, and Molly Mendenhall, BSN, RN, Senior Manager, Quality & Compliance, both at OHC, helped guide the Ohio oncology practice's participation in Medicare's Oncology Care Model program aimed at developing new payment and care delivery models for specialty practices.

Practices participating in the OCM program enter into payment arrangements with financial and performance accountability measures surrounding episodes of chemotherapy administration. Today, 175 oncology practices and 10 payers are enrolled in the program, according to CMS.


In a manuscript published in the Journal of Oncology Practice detailing the success of one OCM participant, OHC (Oncology Hematology Care) in Cincinnati, researchers reported that "implementing a cost-efficient, reproducible, and scalable campaign targeting ER avoidance and hospitalization" enabled the oncology practice to decrease hospital admissions by 16 percent, resulting in an inpatient care costs savings of $3.129 million for Medicare, which covered 1,600 of the oncology practice's patients (2019; doi/full/10.1200/JOP.18.00409.


OHC leadership elected to join the OCM program because they felt it would build upon quality initiatives already established. This includes a phone triage program with specially trained oncology nurses who help patients manage symptoms and side effects. Another service OHC implemented is after-hours and weekend appointments. Concerns that reducing hospital admissions would result in increased ED visits or 24-hour observation stays for its patients were not supported by data compiled about the OCM program shared by CMS' Chronic Condition Warehouse.


The practice transformation efforts required the hiring of additional staff, including more registered nurses and advanced practice providers (APPs), which was a substantial investment for OHC. The community-based oncology practice boasts 20 oncologists, 10 radiology oncologists, three gynecologic oncologists and four bone marrow transplantation specialists, in addition to RNs, APPs, and support staff. The practice serves patients covered by both Medicare and private insurance at 10 sites and serves five regional health systems in Ohio, Kentucky, and Indiana.


Study Details

For the study, the OHC quality research team conducted a comprehensive chart review of 300 patients with cancer and found 60 percent of those patients had sought care in the ED without notifying OHC first.


"Assessing this gap, we were motivated to design a system to improve quality of care while decreasing costs," the quality research team noted. OHC's patient satisfaction scores also increased, fulfilling another foundational tenant of the OMC program.


The OHC research on its participation in the OCM program was initially presented at the 2018 ASCO Annual Meeting, and then later by invitation at the 2018 ASCO Quality Care Symposium, where a second poster outlining strategies supporting the OCM initiative was also presented. An invitation to deliver a verbal presentation of the findings at the 2018 ACCC Annual Meeting soon followed.


A third OHC poster, which outlined the important role of APPs in practice transformation, meanwhile won the Best Poster award at the 2018 meeting of the Advanced Practitioner Society for Hematology and Oncology, and was followed by an invitation to prepare another manuscript for publication, this time for the Journal of the Advanced Practitioner in Oncology.


Recently, OHC earned a competitive grant to improve genetic testing in breast cancer through improved screening and counseling. Going forward, all new patients with breast cancer at OHC will be screened using NCCN Guidelines during their required OCM visit, said lead researcher, David Waterhouse, MD, MPH, a medical oncologist and Co-Chair of the Clinical Research Department at OHC.


What's more, he said electronic health record integration and structured data fields will be designed and implemented to streamline processes and reporting with the help of OHC's partners, including health care IT provider McKesson and The US Oncology Network. The structured data fields will support BRCA testing for breast cancer and then later address other disease states, such as ovarian and prostate cancer.


Although the OCM is focused on providing quality care specifically to oncology patients covered by Medicare, OHC leadership "opted to roll out the process improvements for all of our patients to institute the highest quality of care regardless of a patient's payer," Waterhouse said. "This process of incorporating all patients has been a key driver to OHC's quality success. We felt that if the goal was to reduce unnecessary ER utilization and hospitalization, we should target all OHC patients and not just those eligible for Medicare's OCM initiative."


Below, Waterhouse shares additional insight into the decision to participate in the OCM initiative and the remarkable success of the OHC team of cancer caregivers, who are being honored for their practice transforming efforts with a 2019 Excellence in Oncology honorable mention award from the Oncology Times.


What, if anything, surprised you about the results of your study?


"Although I have been conducting clinical research for more than 25 years, few research projects have been more rewarding than the work we are doing in support of the CMS' OCM program. This project is currently ongoing, and we continue to adapt based on our data collection.


"I think there were two significant surprises thus far. First, although all of us recognize that there is likely a significant amount of waste in the system, it is extremely hard to make a true impact. The reporting from CMS has been exceptionally delayed and this has hindered our progress. We are trying to make changes in real-time while our data is often retrospective, well over a year old. Health care changes at a rapid pace. We have learned to become extremely nimble and make practice changes accordingly to enhance patient outcomes. Simultaneously, we've even had to preemptively adjust our processes in anticipation of the data being released.


"The other great surprise (albeit a very pleasant one) was just how important our successes were to our patients. I was at a fundraiser one night for the Cancer Support Community and during a break in the proceedings I was given a microphone and asked to speak to recent advances in OHC cancer research.


"When I mentioned that we had reduced hospitalizations by 16 percent, I was met with a standing ovation that I did not expect. At the end of the day, these are patients who are home with their families, attending important family events, going to work, and most importantly spending time with their loved ones. This response further galvanized our team's commitment to this quality research program."


Is there anything about the study others are likely to get wrong?


"I have heard that many groups have focused simply on their Medicare-only population. I am not sure you can be successful if you simply carve out one group of patients while not addressing the needs of all patients. The impact of cancer affects all patients regardless of their age or payer."


What are the clinical implications, if any, of your research?

oncology care model.... - Click to enlarge in new windowoncology care model. PERSONALIZING CANCER CARE: As Oncology Care Model participants, OHC's providers take the time to consider each patient's medical, financial, and emotional well-being when creating their cancer care plans. The Medicare program has been so successful for the Ohio oncology practice that it now extends the same level of personalized care to all of its patients.

"The clinical, as well as economic, implications of our work are significant. The purpose of OCM is to improve quality and reduce cost through practice transformation. We implemented a cost-efficient, reproducible, and scalable program targeting ER avoidance and hospitalizations which resulted in a 16 percent decrease in hospital admissions without significantly increasing ER visits or observation stays.


"The hospital admission reductions in year 1 of OCM, resulted in savings amounting to $798,000 in inpatient costs-per-quarter over 1,600 patients, equating to $3.129 million in savings. While the cost savings are very important, it is far more satisfying to know that 16 percent more of our patients were home with their families.


"We have been able to reduce hospitalizations without adversely affecting our patient's quality of life or satisfaction. Further, we have done this without increasing utilization elsewhere, such as the emergency rooms. We believe preventing unnecessary hospital visits also reduces unnecessary risks for patients already immunosuppressed.


"There has also been a significant and positive economic impact as well. Through our efforts, we are reducing the overall cost of the patient's care. It is well-recognized that our nation's resources are limited and must be used wisely and efficiently."


What further research needs to be done on this topic?


"There is a tremendous amount of work to be done. At the national level, the CMS reporting must be improved and become timelier. We also need to find a way to align the interests of all the various health care stakeholders.


"As we reduced hospitalizations, we are also reducing hospitalization revenue. Potentially, this could be problematic for the hospitals. Reimbursement models need to reflect our common goal-to beat cancer. Cancer is the enemy, not each other. At a local level, we are finding that there is a great degree of variability amongst individual providers and geographic sites.


"Health care culture is very difficult to change. Further research is necessary to develop strategies which will promote efficiency along with the highest quality care. Again, there is a need for better reimbursement and funding of such efforts. It is highly likely that the return on investment for practices as well as payers will make these investments well worth it."


Is there anything else you would like to share about your research?


"Quality initiatives require a team effort at every level. Our team, led by Molly Mendenhall, BSN, RN, has proven to be highly effective and productive. Every OHC employee has contributed to the success of this quality initiative and made a positive impact on the quality care delivered to our patients. It is imperative to spend a significant time organizing and educating your team and promoting everyone's efforts ahead of your own."


Chuck Holt is a contributing writer.


2019 Excellence in Oncology