Chicago, IL—Wilshire Oncology’s patient-centered medical oncology home pilot has transformed care by offering maximum support of patients throughout their treatments, including attention to patients between office visits to minimize side effects and symptoms.
Details of the development and engagement process, the plan to aggressively manage symptoms to reduce cost, and the payment methodology were offered by Linda Bosserman, MD, at the 2011 Cancer Center Business Summit. The pilot, launched on June 1, 2011, was developed in conjunction with Anthem Blue Cross, CA, which makes it available to some of its members with cancer living in Los Angeles, San Bernardino, and Riverside counties. “We were able to move beyond breast, colon, and lung, to all of our cancer patients being part of this model for payment,” said Dr Bosserman, clinical oncologist and President of the Wilshire Oncology Medical Group.
The medical oncology home pilot offers additional reimbursement for clinicians, symptom management support by nurses, advance care planning, and collaboration with urgent care centers to reduce the number of costly emergency department visits.
Care transformation requires a re-engineering of the practice “from the ground up,” and has resulted in partnerships with payers and providers that have transformed payment methodology to support desired care, said Dr Bosserman. The development process with the health plan took 3 years.
“We worked for the past 6 to 10 years to re-engineer every step of our practice…being a group, having group meetings, and agreeing to group standards…having data, feeding back data, continuous improvement, working at every level of the staff to be efficient and fully engage the mission,” she said.
Wilshire has contracts to provide care in 2 counties in California, where 26% of patients are uninsured. “We’re up 450% in the patients we care for over 3 years,” she said. “They have never seen such efficiency.”
Engaging payers was an important initial step in the development process to build a medical oncology home. “We started out with our major payer in California, and we had to build a personal relationship,” she said. “I got on the board of Blue Cross of California—I’m on the physician committee that passes all final decisions for the health plan for the state. Attending quarterly meetings gave me access to decision makers.”
Engagement of medical directors, contracting, actuaries, and pharmacy was also part of the process. Validation of the health plan data and comparators was required. The key impactable cost drivers in cancer care identified include the costs of therapy, supportive care, symptom management, site of care, and end-of-life care.
The costs of supportive care identified were the management of nausea/ vomiting, bone metastases, and white blood cell and red blood cell support. “We decided to focus on nausea and bone medicine support,” she said.
Aggressive management of 7 common symptoms (nausea/vomiting, diarrhea, pain, fever, infection, neutropenic fever, blood clots) in the office or at local urgent care centers was a goal to reduce the number of hospitalizations and keep patients from emergency department visits. A partnership was therefore begun with local urgent care centers to see patients who experienced these symptoms after hours. Better oversight of medications, whether oral or intravenous (IV), was determined to improve medication compliance and adherence, leading to better outcomes.
New Payment Methodologies
Standard fee-for-service is still part of the payment methodology for which evaluation and management visits are paid, as are infusion codes and reimbursement for IV and oral drugs, using the average sales price plus 6% methodology.
New payment methodologies included the development of new codes for care planning and care management, “so that care planning goes on for every single patient for every type of treatment—adjuvant, neoadjuvant, prevention, maintenance, consolidation, first-line, second- line, and third-line,” said Dr Bosserman. “Everyone who is on active management has a per cycle management fee.”
The entire care plan is paid for in addition to the office visits. Wil - shire is committed to delivering 6 reports of transparency:
- Number of patients under care and their clinical characteristics
- Therapies patients are taking and the supportive therapy that accompanies them (whether on or off guidelines)
- Potential cost-saving for the regimen chosen compared with a National Comprehensive Can - cer Network–allowable regimen
- Interval care report (events that required an extended office visit or urgent care visit vs emergency department visit and hospital admission)
- End-of-life care report
- Nationally validated quality measures (ie, key American Society of Clinical Oncology Quality Oncology Practice Initiative measures, meaningful use, and Medicare Physician Quality Reporting Initiative).
The program has led to a 25% increased rate overall in the contract. “We’re not dependent on the drug margin,” said Dr Bosserman. “We’ll be doing all of the analytics as to what our costs are to deliver, and whether the 25% increase is enough.”