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    The first grant that Barbara L. McAneny, MD, FASCO, MACP, chief executive officer, New Mexico Cancer Center (NMCC), ever applied for, she got: $19.8 million from the Center for Medicare & Medicaid Innovation (CMMI) to expand a model for an oncology medical home that was pioneered in Albuquerque, N.M.

    Discussing the role of care models and data on July 15 in Denver, McAneny introduced the model — the Community Oncology Medical Home, or COME HOME — through the story of Larry, an octogenarian pancreatic cancer patient who had hopes of traveling out to Las Vegas in the near future but was faced with a possible hospital admission.

    In another setting, Larry may have had an expensive ambulance ride to the emergency department, which would lead to a wait, a code status inquiry, a query on smoking, a check of A1c and a variety of other quality measures that didn’t help his main concern: an infection that turned out to be septic shock.

    Luckily, Larry was being cared for by NMCC, leading to a much different outcome: They pulled up the triage pathways that account for early warning signs, figured out what Larry’s issues were, had him come in and cultured him for infection and started a first dose of antibiotics, along with a high-resolution CT scan for his lungs.

    By the time that the hospital had a bed available for Larry, he was up and alert and begging to not be admitted to the hospital so he could still make his trip to Vegas.

    That quality of life concern isn’t limited to Larry, McAneny noted — after a hospitalization, there’s “a step down,” she said. Keeping patients out of the hospital became a driving force for her practice, taking that $19.8-million grant to duplicate the triage pathways model across the county, building it into software so that nurses can ask specific questions about symptoms and have the power to schedule patients (rather than pleading with doctors), and putting in the initial orders.

    Paired with after-hours clinics, same-day appointments and new patient engagement efforts, the COME HOME program at NMCC, compared to the period before the COME HOME program, saw a 35.9% drop in patients with ED visits and a 23.8% drop in inpatient days. The program also lowered total cost of care over a six-month period and cost Medicare about 11.5% less than similar patients in the Albuquerque metro area.

    “We saved Medicare $2,100 per patient,” McAneny said, which when extrapolated likely saved Medicare $36 million — a solid return on that $19.8-million investment, to say nothing of the improved care.

    Finding these new models of care and cost savings are crucial, McAneny continued, as the rate of healthcare cost increases become unsustainable.

    “We have to do something … We don’t want to do it by rationing,” McAneny said. “We need to do it by working smarter.”

    One key area promoted by CMMI to this end is the Oncology Care Model (OCM), which defines a six-month episode following a new chemotherapy start. The core of the OCM was a normal fee-for-service (FFS) payment, along with two other payment methods: a $160 per-beneficiary, per-month payment (PBPM), and shared savings/risk sharing.1

    Having data to prove where savings spring from was important, McAneny noted.

    “I could show that the cost of paying for nurses to be on the phone and talking to patients was key to COME HOME,” she said. “That’s what saved the money: patient education and caregiver education.” Accounting for nurse salaries and their time outside the FFS payment working on talking to patients led to the $160 PBPM.

    Overall, the OCM model promoted improved patient care and earlier interventions with patients to keep them out of the hospital, but not without significant challenges regarding documentation, low payment rates and the difficulty posed by EHRs lacking robust care coordination functionalities.

    Areas of savings beyond the ED utilization reduction included reduction of duplicated services (such as labs and imaging), better symptom management and advance care planning.

    However, some of the major concerns with this type of alternative payment model has been the burdens on providers to deliver on the data to demonstrate performance. “If you spend your time entering data into a computer, your hospital can get a better star rating and your CEO gets a bonus, but all you get is being late for dinner,” she noted. “That is not a very motivating thing for a physician.”

    To help take the lag time out of looking at claims data, McAneny said she is working toward a real-time oncology payment model dubbed MASON — Making Accountable Sustainable Oncology Networks — that “builds on the principles of [COME HOME],” the OCM, FFS payments and more to “use a combination of claims and clinical data to create an Oncology Payment Category (OPC) visible online to practices and CMS, that does not require revision of already existing payer or financial software systems.”2

    Notes:

    1. Centers for Medicare & Medicaid Services. “Oncology Care Model overview.” February 2019. Available from: bit.ly/2Yf3zcL.
    2. McAneny B. “MASON – Making Accountable Sustainable Oncology Networks.” Feb. 18, 2018. Available from: bit.ly/2ZkhnPo.
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