A Tough State Makes a Tender Practice

Barbara McAneny, MD

New Mexico Cancer Center has a proud record of innovation—its managing partner helped create the Community Oncology Medical Home (COME HOME) model in 2012—but the Albuquerque-based practice has still spent much of the past five years fighting to maintain its independence.

Geography and demography alone would make New Mexico a challenging place to provide a wide range of cancer care. The state is one of the poorest and most sparsely populated in the nation. Roughly 12% of New Mexicans have no health insurance, according to the Henry J. Kaiser Family Foundation, and many of the state’s people live in areas far too rural to support specialty medicine.

The healthcare market around Albuquerque, the largest city in New Mexico, is also challenging for an independent practice. Presbyterian Health Plan has a more than 50% share of the market for private insurance patients, which makes its parent company, Presbyterian Healthcare Services, the dominant regional provider, said Barbara McAneny, MD, the CEO of New Mexico Cancer Center. Another pair of private insurers—United Healthcare and Cigna—also have deals that send nearly all of their policy holders to Presbyterian, which owns the majority of the area’s medical facilities and employs the majority of its physicians.

“Presbyterian told us years ago that we had the choice of becoming employed by them or being put out of business. United and Cigna are linked to Presbyterian. We launched anti-trust litigation and we have maintained our service agreements while the case remains in court,” McAneny said. Presbyterian is attempting to avoid paying non-Presbyterian doctors.

“Losing access to more than 50% of the privately insured patients in our largest market would be devastating. Like all independent oncology practices, we survive on independently insured patients. Medicare and Medicaid simply don’t pay enough right now to cover the cost of care.”

New Mexico Cancer Center has undertaken several initiatives to decrease its reliance on Presbyterian and its corporate allies, starting with geographic expansion.

In addition to its main office in Albuquerque, there are now satellites in Gallup (140 miles west) and Silver City (284 miles southwest). Gallup has a population of 22,000, and Silver City, 10,000, according to the US Census. Neither of these two towns could support a stand-alone oncology practice with chemotherapy, radiation, surgery and imaging, but New Mexico Cancer Center operates such that the small town offices are effectively sharing resources.

“A medical oncologist drives to Gallup Monday morning, works two days there and drives home Tuesday night, and our radiation oncologist drives out every Wednesday. Another medical oncologist is there Thursday and Friday,” said Nina Chavez, the practice’s chief operating officer. “The Silver City office is so far from Albuquerque that we actually fly people back and forth.”

Sending doctors so far from the main office benefits patients who live hours from any large city and need local access to specialty care. The practice, moreover, gets access to patients who live far outside of Presbyterian’s service area.

Extending services to smaller population centers isn’t the only innovation to come from McAneny and her team. In 2012, The Centers for Medicare & Medicaid Innovation awarded her, through her company Innovative Oncology Business Solutions, $19.76 million to develop a model for improving cancer care that has come to be called COME HOME. It is a specific blueprint—based on the policies and procedures developed at New Mexico Cancer Center— designed to enable practices across the country to transform themselves step by step into oncology medical homes.

An Upfront Investment Saves Money

Among the most important differences between an oncology medical home and a traditional practice is patient access. Patients must be able to contact the practice 24/7 and get good medical advice over the phone. When symptoms warrant in-person treatment, patients must have access to sameday appointments, even on weekends. If all goes according to plan, patients are healthier and make fewer visits to the emergency room, which reduces the risk of serious complications and increases quality of life.Staffing triage telephone lines with well-trained people and developing algorithms that enable staff to advise patients properly are expensive, as is leaving many appointment slots open for emergencies. However, analysis by the University of Tennessee indicates that the system created and implemented by New Mexico Cancer Center saves far more than it costs. Hospitalizations fall by half, and those that do occur are shorter. Total annual savings per Medicare patient are estimated to be $4,178 per year. Net savings (after paying for extra costs at oncology practices) are estimated to be $1,715 per patient per year.

COME HOME isn’t the only detailed blueprint for operating an oncology medical home, but it is probably the most widely recognized to date. The American College of Surgeons’ Commission on Cancer has accredited only 10 oncology medical homes nationwide, and all seven that use the COME HOME model are on the list.

“We’re extremely proud of what we created. Our patients are healthier and happier. The overall cost savings are significant. For the time being, though, we’re actually losing money by operating this way,” McAneny said. “With the exception of Blue Cross, payers have not been compensating us for the extra costs on our end. They’ve been free-riding: paying us as usual and pocketing all the savings. That’s about to change with Medicare, and that transition to pay-for-performance will be a huge win for us, but we’ve had no luck with the private insurers other than Blue Cross.”

Although New Mexico Cancer Center has yet to profit from COME HOME, the model is helping its patients financially. Although patient copays for ambulance rides and emergency room visits are typically high, there is no charge for calls to the triage line, and cancer center visits typically cost patients $20.

Saving money for patients is a constant consideration for a practice that treats so many people who live near the poverty line. Partners periodically review standard diagnostic and therapeutic pathways to eliminate nonessential care. Small actions—such as arranging for a patient’s hospital admission rather than sending the patient to the emergency room—can save significant amounts of money.

New Mexico Cancer Center has also created a charitable foundation to help patients with nonmedical expenses associated with cancer care. The foundation raises money through quarterly art auctions and other initiatives. The proceeds go to help patients with everything from transportation costs to electricity bills. To date, the foundation has given away about $1 million and kept dozens of patients from declaring bankruptcy. “Our patient navigator and our financial counselors identify which patients are in need of help and refer them to the foundation,” said Chavez.

McAneny hopes that more practices try something similar. “Practices are in an ideal position to undertake this sort of effort,” she said. “It’s hard for a separate charity to identify needy people and help them in the most effective way. Caregivers, on the other hand, have deep and longlasting relationships with patients. We know these people.”

Although New Mexico Cancer Center operates two satellite offices more than 100 miles from its home base, it does not scatter its resources around Albuquerque. Unlike many big independent practices, which try to save patients drive time by blanketing a single metro area with many small offices, New Mexico Cancer Center concentrates its Albuquerque resources in a single building.

The practice’s current facility opened in 2002, 15 years after McAneny started the practice with a single partner who has since retired. The main cancer center now has 10 medical oncologist-hematologists, three radiation oncologists, four internists, a radiologist, and a rheumatologist. Having so many people all in the same place allows New Mexico Cancer Center to offer more services than it could provide from a dozen mini offices. Operating a single office is also more efficient, so it significantly reduces costs. McAneny has other ideas for reducing costs, both for patients and payers, but she has found it difficult to test some of them.

“I’d really like to be able to waive the copay for emergency office visits. That would obviously save money for patients, but I think it would also save money for insurers by further reducing emergency room visits. There are patients who wind up in the ER because they won’t come in when their symptoms warrant a visit,” McAneny said. “Insurers think that people will come in needlessly if they don’t have any copay, but experience tells me otherwise. No one comes to an oncologist if they don’t have to.”