Illinois Cancer Center Looks to Get Ahead of the Value Curve

Alexander Hantel, MD

At Edward Cancer Center in the affluent Chicago suburbs, patients generally have good insurance, donors have contributed millions of dollars to capital campaigns, and sophisticated services like multi-disciplinary care coordination and patient navigators are supported by the center’s parent hospital.

Yet despite its healthy finances, Edward is eagerly hoping to be selected to participate in the Centers for Medicare & Medicaid Services’ new Oncology Care Model (OCM), a pilot program that will require the cancer center to measurably cut costs even as it beefs up its services and analytical capabilities.

“We've always worked in a situation where our only concern has been the care of the patient, which is fine. That's the way it should be,” said Alexander Hantel, MD, the center’s director of medical oncology. “But at the same time we also are realizing as physicians that the value of what we prescribe for patients has to be more carefully assessed.”

The push for greater efficiency comes at a time of growth for the center, which was established a decade ago when Edward Hospital in Naperville, Illinois brought its visiting oncologists onto its staff. A second site opened nearby in Plainfield in 2009. From 2005, when the center treated 1135 cases, volume at the two sites grew to 1386 in 2011 and to 1850 last year, said administrative director Jenna VanGilder.

The center has 7 medical oncologists, 4 radiation oncologists, 2 surgical oncologists and 7 advanced practice nurses. A third surgical oncologist is coming on in August.

Hantel said he wants to join the Oncology Care Model to address the ever-increasing cost of cancer drugs, or at least to help CMS assess the merits of a new approach. VanGilder said participating would give Edward the jump on cost-containment mandates that all oncology practices could be forced to adopt a few years from now.

“There's obviously some scary things about the model that we know that we don't do that great, but we also realize that we probably should. So why not learn along the way and figure it out now, rather than wait?” she said.

Despite its money-saving potential, the Oncology Care Model has taken some criticism for preserving traditional fee-for-service (FFS), tying incentive payments to factors the oncologist does not control, and for paying according to “arbitrary” 6-month treatment episodes.1 ASCO’s preferred alternative, called Consolidated Payments for Oncology, would depart from FFS by switching to relatively large payments at the start of treatment and every month, as well as payments during treatment holidays and after treatment ends.2 Pay would be cut for practices that don’t follow guidelines for prevention of complications, end-of-life care, and use of drugs, testing and imaging.

Edward, however, has embraced the OCM. In addition to moving to the edge of payment reform, Edward would benefit from the model’s $160 monthly per-patient fee, which is intended to cover coordinated care and other improvements in treatment of chemotherapy patients, VanGilder said.

“We offer a lot of these things already, and we're not getting the extra per-beneficiary payment per month. We do provide a lot of that care coordination,” she said. “Not that we're going to make money by any means, but to get some reimbursement to assist with these resources would be nice.”

The care coordination comes via specialized clinics for lung, brain, breast, gastrointestinal and genitourinary cancer. The lung clinic, for example, has a dedicated surgeon, medical oncologist, radiation oncologist, pathologist, radiologist, and psychosocial and research staffers, VanGilder said. The physicians meet weekly to discuss cases and plan treatment, and an advanced practice nurse arranges appointments and shepherds the patient through.

The cancer center and Edward Hospital have also been on the forefront of meeting quality standards of the type required by the Oncology Care Model, Hantel said. They include ASCO’s Quality Oncology Practice Initiative Certification.

“We're probably a relatively high cost practice just because we are in a high-reimbursement and high-utilization region of the country. But at the same time, we have always done all of the quality improvement measures,” he said. “We're way ahead of the curve in terms of really trying to give good quality care and do it in a measurable way in our practice. So we have every certification you could think of.”

Hantel said his only major concern about the OCM relates to the long-term sustainability of the model’s incentive scheme.

“In the short term there's no real downside for us to participate. It's a carrot and stick approach. The carrot is coming out right now,” he said. “The question is, what's the stick going to be down the road? And how many percentage points are we going to be asked to ratchet things down every year beyond that point? If you're really, really efficient, it's going to be hard for you to ratchet things down after a while. That's the problem.”

“If you become accustomed to the revenue from the program and then you don't get it all of a sudden, that's a bigger hit,” he said.

The OCM has attracted significant interest so far. About 450 practices have submitted letters of intent, though some may back out once more details of the model are released. CMS has suggested it will enroll about 100. There are four selection criteria, worth up to 100 points: 40 for implementation plan, 25 for financial plan, 30 for payer participation and 5 for patient diversity.

The criteria pose some hurdles for Edward. The center may not score well for diversity, VanGilder said, and it has so far not confirmed that any of its insurers will agree to set up their own payment arrangements similar to the OCM, which could hobble its application. She said the center is in discussions with its second biggest payer, Blue Cross and Blue Shield of Illinois, and is hopeful that the company will sign on.

If Edward is selected, it will face a set of complex administrative challenges as it works to meet the OCM’s goals. One is survivorship, which is basically care coordination after treatment ends and patients stop coming to the cancer center. Such efforts ensure patients get recommended follow-up care to minimize recurrence of disease while avoiding duplicative testing, and should ultimately reduce unnecessary costs.

“Survivorship is just a huge ball of wax, and we haven't quite gotten that all together yet,” VanGilder said. “You should give be able to give patients a printout of everything that's happened to them and recommendations for follow-up care and health promotion activities. That can be very cumbersome, because no electronic record is pulling in all that information like you would want it to. You have to spend 2 hours filling out a form for a patient.”

“And it's difficult to catch patients at the point of survivorship, too. Every cancer patient is unique. Some get chemo and they're done; those might be easier to catch, so you can make sure they get their survivorship care plan. But then maybe others end up going to radiation, or then they go to surgery. How do we make sure we can catch them at those points? Those are things we struggle with,” she said.

Among other requirements, OCM practices will have to start providing new patients with accurate upfront estimates of their out-of-pocket costs before treatment begins. That requires understanding the vagaries of every patient’s insurance plan. And even though Edward has lately expanded its palliative care program, as part of OCM it would probably also have to allocate more staff time to discussing end-of-life issues with patients, VanGilder said.

The biggest unknown stems from the Oncology Care Model’s shared savings component. CMS will set benchmarks for the cost of chemotherapy episodes and make incentive payments to practices that come in at 4 percent below the target. Practices that don’t meet benchmarks and performance measures could be booted from the program. Yet the target prices have not yet been announced, making planning tricky.

At the same time, Edward’s relatively high cost structure suggests it does have opportunities to become more efficient and spend less regardless of the targets.

Some of that will involve counseling savvy, well-insured patients not to demand care that may not be necessary, such as after-hours emergency room visits or imaging for unexpected pain, VanGilder said. Data analysis suggests that Edward’s staff need to initiate discussions about hospice care sooner, which can be particularly difficult with the center’s large cohort of younger breast cancer patients, she said.

“Are you giving chemotherapy in the last week of somebody's life? Is that the best practice? We don't do very well on that measure,” VanGilder said. “That's why we probably need more advanced care planning and more frank discussions with patients.”

For now, Edward is focused on the success of its application, which was due June 30. CMS will notify applicants of their status around the end of year. If the center is not selected it may pursue an OCM-like strategy anyway, VanGilder said, because oncology is inexorably moving in the direction of better understanding and tighter control of the costs of care.

“Quite honestly, if we aren’t chosen we're really hoping maybe another payer will be interested in doing it with us, or we will try to look at this model and implement things on our own, knowing that this is going to happen,” she said. “Do we really understand the cost to care for cancer patients? We haven’t figured out a great way to give patients an estimate of total costs and out of pocket costs. The model is making us really think about that.”

References

1. Polite BN, Miller HD. Medicare innovation center Oncology Care Model: a toe in the water when a plunge is needed. J Oncol Pract. 2015;11(2):117-119. http://jop.ascopubs.org/content/11/2/117.full. Accessed June 14, 2015.
2. American Society of Clinical Oncology. Patient-Centered Oncology Payment: payment reform to support higher quality, more affordable cancer care (PCOP). http://www.asco.org/advocacy/asco-releases-payment-reform-proposal-support-higher-quality-more-affordable-cancer-care. Published May 21, 2015. Accessed June 14, 2015.