COME HOME Program Lowers Costs for Cancer Patients

Kristin Jenkins

December 27, 2016

When the pilot Community Oncology Medical Home (COME HOME) program was awarded a $19.76 million, 3-year grant from the Center for Medicare & Medicaid Innovation in 2012, it quickly proved effective at reorganizing community oncology practices in a way that enhanced cancer patient care while significantly reducing costs.

Early results from the pilot program in seven US practices show that the rate of inpatient hospital admissions was reduced by 12.5%, 30-day hospital readmissions were reduced by 11.7%, and emergency department visits were reduced by 6.6%. The overall cost of care was slashed by 7.2%.

But of all the lessons learned, perhaps some of the most profound have come from a better understanding of the patient experience, said Barbara L. McAneny, MD, CEO, and medical director of Innovative Oncology Business Solutions Inc (IOBS), which pioneered the COME HOME model.

Dr McAneny is also managing partner and CEO of the New Mexico Cancer Center in Albuquerque, one of the free-standing non-hospital-based practices enrolled in the pilot program.

To find out what it's like to receive care after a diagnosis of cancer, she asked patients directly.

What she heard took her aback, but it also underscored the fact that the COME HOME model was on the right track.

A diagnosis of cancer often signals the beginning of the end financially for many families, patients explained. As debts pile up to cover the high cost of cancer care, even those with insurance can see their life savings disappear, followed by the kids' college funds and then everything else.

"In too many cases, families are forced into bankruptcy, losing everything, including the family home," Dr McAneny told Medscape Medical News. "I became concerned about not bankrupting my patients."

Dr McAneny realized that patients needed care that did not automatically trigger insurance costs. She also knew that at least in New Mexico, there were but two immutable variables: the high cost of drugs, and an average annual income of $16,000.

"We have to do everything we can to keep down copayments and deductibles, not just for the patient but for the patient's entire family," Dr McAneny explained. "Half of the state is on Medicaid. We have a lot of other things going for us, but it isn't money."

Program Is Uniquely Positioned

The COME HOME program is uniquely positioned to keep insurance costs from kicking in by keeping patients out of the emergency department and reducing risk for hospital admission.

"We see a lot of patients in tears because they have a fever and it's a Sunday afternoon," Dr McAneny said. "Instead of going to emergency, we tell them that they can come here for early intervention."

One 86-year-man with metastatic pancreatic cancer was brought in by his family because he had developed severe confusion. Tests quickly revealed he was in septic shock, and within an hour and a half of arrival, he was receiving antibiotics.

"All of his blood cultures eventually grew E coli," noted Dr McAneny.

Although the patient had to be admitted to hospital, his length of stay was 2 days instead of 10, and he did not need to be admitted to the intensive care unit.

Some of the worst-case scenarios unfold in male patients who are without caregivers, Dr McAneny notes. "That's the toughest group because they're often alone and frightened."

When it became evident that many of these solo patients were declining same-day appointments, Dr McAneny and clinic staff — which includes 16 physicians plus nurse practitioners and physician assistants — conducted a 2-week study to find out the reasons behind these refusals.

The study revealed that one third of patients did not have transportation and that about 20% were afraid of having to make an insurance copayment. The rest of the study participants said they had decided to "tough it out for no good reason," Dr McAneny said.

On the basis of this feedback, a follow-up telephone call was made part of the protocol. Now, when people call in but refuse a same-day appointment, they receive a telephone call 2 hours later for a status report. Those who are not feeling better are encouraged to come in.

A follow-up patient satisfaction survey showed that despite initial hesitation, 95% of patients who decided to take the appointment "were thrilled to have the opportunity to come in and be seen," said Dr McAneny. "The patient satisfaction was very high."

Community-based Cancer Care

For Ted Okon, executive director of Community Oncology Alliance, an organization that advocates for community-based cancer care, the idea of 24/7 care that includes telephone triage, night/weekend clinic hours, and on-call oncologists is very important to patients.

He remembers the day he escorted a cancer patient to a meeting on Capital Hill in Washington, DC, with then Senator Sharon Brown from Ohio. The patient wanted to tell the senator in person just how much the COME HOME program meant to her entire family.

The patient was accompanied by her husband, who was blind, his seeing-eye dog, and their 10-year-old son, Okon recalled.

Instead of going to the local emergency department, sitting for hours, and possibly being admitted, the woman was treated for severe dehydration at the Dayton Physicians' Network, which had just opened as a COME HOME practice. Then she got to go home.

"She told Senator Brown that it was so much easier than if she had gone to the ER," said Okon.

Another cancer patient with excruciating foot pain was on her way to the emergency department one weekend when she remembered being told to call the clinic first. Her ingrown toenail was treated and dressed, and she "went on her way, happy and pain free, another ER visit averted," Okon remembered.

"The ER is the worst place for the immunocompromised cancer patient," he pointed out.

It can also be a very expensive place, noted Barry Russo, CEO of the Center for Cancer and Blood Disorders in Fort Worth, Texas, another COME HOME practice.

"Any time that we prevent patients from being forced to go to an ER or [to undergo] inpatient hospitalization, we are saving them $3000 to $10,000 in costs on average," he told Medscape Medical News. "We had a 25% reduction approximately in hospital utilization with our COME HOME patients, so I feel confident we've made an economic impact for them."

One patient at the Fort Worth clinic had such overwhelming anxiety before her cancer treatments that she was going to the emergency department before appointments. On some occasions, she was admitted to hospital.

After realizing this was a trend, a case manager at the Fort Worth center spoke to the woman and her husband about what was happening and how it could be managed.

The day before the next cancer treatment, the case manager called the patient to remind her to take her new antianxiety medication. The morning of treatment, the case manager called again to reassure the patient that everything was going to be okay.

"All the ER visits stopped, and the problem was resolved," said Russo. "I know it sounds so simple, but this kind of stuff happens all the time. The hyperfocus on the patient allowed by COME HOME has had significant impact on so many patients."

Ray Page, DO, PhD, president and director of research at the Forth Worth center, remembers a patient with breast cancer who had developed intractable nausea, vomiting, and diarrhea after chemotherapy. She was severely dehydrated.

Because the clinic's satellite office was closed when the patient arrived without warning at 7:30 am, she drove around the corner to a nearby hospital. She was sitting in her car in the parking lot outside the emergency department when she decided to try calling the clinic just in case it had opened.

It hadn't, but the call went to a triage nurse, who told the patient to stay where she was. Then the nurse called Dr Page and gave him the patient's telephone number. He was finishing his hospital rounds.

Dr Page met the patient in the parking lot. She was still sitting in her car. After a quick examination, he instructed the patient to follow him back to the clinic, which was now open.

"I got her immediately plugged into hydration and nausea meds," he recalled. "Three hours later, she felt fantastic and was singing the praises of our office. She was also very happy that she did not have to pay the $600 copay required for an ER visit."

Sometimes, a quick response to an urgent care need can mean more than wear and tear on the patient or a precipitous dip in the bank balance: it can be lifesaving. Such was the case with a patient at the Fort Worth clinic whose daughter called to cancel an appointment.

Her mother was feeling unwell and was experiencing increased shortness of breath. She did not want to get out of bed, the daughter explained.

Again, the call went to a centralized telephone triage nurse.

"If this call had been handled by a nonclinical front office staff, they would have said, 'Sure, 10:00 am next Wednesday,' " Dr Page said.

Instead, the triage nurse, who was familiar with the patient's clinical situation, saw a red flag and told the daughter that her mother needed to be seen right away.

A CT scan at the clinic revealed a large pulmonary embolism, and the patient was directly admitted to hospital for anticoagulation therapy and stabilization.

"If she had been rescheduled and stayed at home, she could have easily died that night," noted Dr Page.

Avoiding Hospitalization and the ER

There are many success stories within the community oncology group practices in the COME HOME program. Dr McAneny points to New England Cancer Specialists in Scarborough, Maine, saying, "They did a knock-it-out-of-the-park job."

"We've definitely bent the admissions curve when it comes to preventing oncology patients from having to be admitted to hospital from the ER," said Tracey Weisberg MD, president and lead physician at the Scarborough center.

Dr Weisberg gives full credit to the specialized triage pathways used by nurses to interpret urgent needs of patients throughout the day and on weekends. Even when a patient arrives with a fever that requires being sent on to the nearest emergency department, the patient will have a chest x-ray and the results of a blood panel with them and so will be managed as an outpatient.

"It's just more efficient," said Dr Weisberg. "We've reduced emergency visits in our patient population from 34% to 17%."

Dr Weisberg credits the four financial advocates at New England Cancer Specialists with doing the "bang-up job."

The financial advocates meet with patients who need assistance with copayments and help them apply to various foundations that can lend financial support, perhaps providing money for a couple of mortgage payments so the patient can keep up with insurance premiums.

At least one third of patients require financial assistance, Weisberg pointed out. He noted that these patients are not always socioeconomically disadvantaged.

"The patient who needs financial assistance can be an upper-middle-class person with a great job and a $10,000 deductible on their health insurance," she explained. "But they're sick, and disability hasn't kicked in yet. Since it's October, they have a big copay by the end of the year and are looking at another $10,000 on January 1st. All of a sudden, they have to come up with $20,000."

An informal survey of patients' financial well-being at the New England cancer center revealed that 30% did not have $1000 in savings.

OCM Initiative: "It's About Care Coordination"

New England Cancer Specialists is now one of almost 200 physician group practices and 17 health insurance companies across the US that are participating in the 5-year Oncology Care Model (OCM) initiative.

The initiative is one of the first physician-led specialty care models after COME HOME. It was launched by the Centers for Medicare & Medicaid Services (CMS), on July 1, 2016, and will run until June 30, 2021.

Physician practices will receive performance-based payments from Medicare that will cover about 155,000 Medicare beneficiaries at no cost.

"It takes COME HOME to the next level to share financial risk with Medicare by streamlining processes," Dr Weisberg said. "It demonstrates that you can save money and still maintain quality at benchmarks."

It's not about saving money by withholding expensive drugs, Dr Weisberg emphasized.

"In order to be successful in the oncology care model, you have to transform your practice like a COME HOME program without impairing patient care. It's all about care coordination."

The COME HOME model has worked so well that on November 1, the American Society of Clinical Oncology (ASCO) announced it was joining forces with IOBS to launch its own oncology medical home program, called ASCO COME HOME.

The ASCO COME HOME program will be available in January 2017 and will assist oncology practices preparing to enter alternative payment models, including Quality Payment Program-authorized models, as directed by the Medicare Access and CHIP Reauthorization Act (MACRA).

"Initial COME HOME practices have shown the model's effectiveness at improving health outcomes, enhancing patient care experiences, and reducing cost that will position practices for success in the transition from the current fee-for-service model to providing value-based cancer care," Stephen S. Grubbs, MD, ASCO vice president of clinical affairs, said in an email.

Practices interested in advanced alternative payment model participation can use ASCO's COME HOME practice assessment tools to gauge their readiness for the transition to an oncology medical home, he told Medscape Medical News.

The program also has implementation tools for practices that are ready begin the transition.

"Aside from providing a clear path for transitioning to an APM, ASCO COME HOME is designed to provide direct support to help practices establish comprehensive and coordinated oncology care in the new value-based health delivery landscape that will support their activities in the new Merit Based Incentive Program of the CMS Quality Payment Program," he explained.

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