What does CMS consider to be innovative oncology care? The following three programs won a CMS Health Care Innovation Award for their initiative.
- Community Oncology Medical Home (COME HOME). This model relied on three key principles: (i) triage pathways to help first responders and nurses identify and manage patient symptoms; (ii) enhanced access to care through a 24 hour triage phone line, extended weekday hours and weekend hours, same-day appointments, extended night and weekend hours; and (iii) reliance on evidence-based standards to guide clinical decision making, diagnosis, and treatment. The probram also leveraged and integrated EMR system. Symptom management was focused on management at home or in outpatient settings.
- Patient Care Connect Program (PCCP). This patient navigation interface “used nonclinical navigators to educate and empower cancer patients and survivors, connect patients and caregivers with resources, and improve adherence to care plans.” The naviagtors acted as advocates and liasons between patients and providers. The program’s Respecting Choices initiative helped patients with advanced end-of-life care planning.
- Comprehensive Assessment with Rapid Evaluation and Treatment (CARE Track). This program used nurse coordinators to promote palliative care for patients with advanced stage cancer.. The program relied heavily on the Patient-Reported Outcomes Measurement Information System (PROMIS) measures to evaluate patient pain and discomfort and identify ways palliative care could alleviate these symptoms. Some patients also had access to condensed radiation treatment.
Colligan et al. (2017) examine how these programs perform. They find the following:
Comparing participants in each model who died during the study period to matched comparators, we found that the oncology medical home and patient navigation models were associated with decreased costs in the last ninety days of life ($3,346 and $5,824 per person, respectively) and fewer hospitalizations in the last thirty days of life (fifty-seven and forty per 1,000 people, respectively). The patient navigation model was also associated with fewer emergency department visits in the last thirty days of life and increased hospice enrollment in the last two weeks of life.
Although these innovations may be worthwhile, it should not be surprising the CMS is focused on rewarding models that aim to reduce the cost of care. The reason for this bias is that CMS’s Oncology Care Model (OCM) relies on a payment model that targets chemotherapy and related care during a 6-month period that begins with receipt of chemotherapy treatment. Practices receive two types of payment: (i) the Monthly Enhanced Oncology Services (MEOS) Payment and the (ii) Performance-Based Payment (PBP). The formers is meant to cover general costs of paying for the patient and the latter aims to provide bonuses for practices that improve quality and reduce cost.
Practices that reduce cost and maintain a minimum level of quality receive bonuses. However, practices that provide excellent care but at higher cost receive not additional PBP. Thus, cost savings is a necessary condition for any bonus. Additionally, quality is measured through 12 broad measure. Although collecting separate measures for each tumor type is not feasible, it is clear that these 12 simple measures may do a poor job of capturing the real quality of care that patients care about.
Although measuring quality of care is a good thing, we should be cautious when administrators use quality of care to determine reimbursement rather than use it to to help inform patients and physicians surrounding what quality care means for each individual patient.
- Colligan, Erin Murphy, Erin Ewald, Sarah Ruiz, Michelle Spafford, Caitlin Cross-Barnet, and Shriram Parashuram. “Innovative Oncology Care Models Improve End-Of-Life Quality, Reduce Utilization And Spending.” Health Affairs 36, no. 3 (2017): 433-440.