Integration across the Spectrum: Community Perspective on the Medical Oncology Home Model 

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The takeaway message is that the partnership within our group and with the payers keeps evolving. The end result is high-quality, cost-effective care that is validated by outcomes, measurement, and reporting.

—Linda D. Bosserman, MD, FACP

The term “patient-centered cancer care” has become ingrained in today’s health-care vernacular. However, no matter what modifications occur in clinical oncology practice, the terms value and cost-effectiveness are now a solid part of the equation. At ASCO’s Quality Care Symposium, Linda D. Bosserman, MD, FACP, President of the Wilshire Oncology Medical Group, spoke about how to achieve value and quality in today’s challenging economic setting.

“We are in the Wild West California. A few years ago, our group was offered a capitated contract basically on a take-it-or-leave-it basis. So, we took it and fully evaluated the care we were providing and how that would fit into a monthly fixed payment with few drug carve-outs and a potential annual bonus only if the whole physician group did well. We then had to figure out how to work within a capitated environment and still maintain the value that we pride ourselves on,” said Dr. Bosserman.

The Wilshire Group has seven treatment centers in Southern California and, in 2010, entered into an alliance with Texas-based US Oncology, which was subsequently purchased by McKesson Corporation.

 A Culture Change

“Our move to patient-centered care [and the team-based “medical home” model] was a significant culture change that took leadership and a reengineering of the practice and patient experience to one in which the patient is totally engaged as a partner. We also had to be fully committed to work with the payer; this becomes a relationship more than a contract,” said Dr. Bosserman. She added, “Our patients are being driven out of the PPO [preferred provider organization] market because of high premiums and copays, so it is just as important for us to be cost-effective across the whole continuum of care.”

Dr. Bosserman noted that her group moved to customizable electronic medical records in 2005, which helped them program decision support and collect a comprehensive picture of their treatments. “Our hypothesis was that delivering cost-effective care using evidence-based guidelines, with comprehensive care coordination and management, can lower costs and improve health outcomes and satisfaction, from prevention to end of life,” commented Dr. Bosserman.

Reengineering the Practice

“It is important that physicians in your practice assume leadership roles. We partner at every level of our group’s system; it is a cooperative model, not hierarchical. We have comprehensive monthly clinical meetings, in which we discuss pathways and review our new patients and our data. There is nothing that changes physician behavior quicker than feedback,” stressed Dr. Bosserman.

Dr. Bosserman added that reengineering the doctor-patient relationship is also a central component of the medical home model. “We make sure that all our patients are educated about their treatments. We encourage them to call us, which reinforces the concept that we are there for their all health-care needs. We have a proactive call service that contacts patients, with a built-in patient satisfaction survey to be added next year,” said Dr. Bosserman.

Medical Home Model

Dr. Bosserman explained how her group transitioned within the fairly hostile capitation environment to the medical home model. “Several years ago I went on the board of our local individual practice association and began sharing data about our outcomes and cost savings. This generated a lively series of substantive meetings. I then contacted the chief medical officer at Anthem Blue Cross, our largest payer in California, and we gradually developed an idea that wasn’t immediately “ready for prime time.” We launched the medical oncology home pilot model about a year ago,” said Dr. Bosserman.

The first step was identifying the key cost drivers in five categories: therapies, supportive care, symptom management, optimizing site of care to prevent hospital visits, and end-of-life care. “For instance, we saved a significant amount of money by using guidelines from ASCO and NCCN, as well as our internally identified cost-effective pathways (like US Oncology Network’s Level 1 pathways) to choose drug regimens with benefits equal to those of higher-priced therapies. We also had substantial savings by providing proactive relief of seven common symptoms, any of which can also lead to unnecessary, expensive ER and hospital visits,” said Dr. Bosserman.

“We looked at whether our choices of cost-effective regimens were less than the California average and certainly less than the highest-cost option on the National Comprehensive Cancer Network [NCCN] guidelines. And we realized that our treatment planning fees made up the difference between the California costs, so we actually came in at lower than the state average, and well below the NCCN costs. Clearly, measurement and planning can be done, and we can be paid for our services in a way that is consistent with the cancer care system staying in business,” said Dr. Bosserman.

An Evolving Model

“We learned that delivering high-quality patient-centered care is possible as long as it is evidence-based and outcomes-driven. Our group treats patients in two counties in California that each have populations greater than those of 15 states, so broad access across the spectrum of patients is achievable. Moreover, working in partnership with the payer, we learned that some of the generic drugs we were using were more expensive than alternative generic therapies,” Dr. Bosserman continued.

“The takeaway message is that the partnership within our group and with the payers keeps evolving. The end result is high-quality, cost-effective care that is validated by outcomes, measurement, and reporting. This is really what we went into medicine for; it’s just a new way of looking at it,” concluded Dr. Bosserman. ■

Disclosure:Dr. Bosserman reported no potential conflicts of interest.