The Do-It-Yourself Medical Home

Craig R. Hildreth, MD

“Innovative Oncology Business Solutions, Inc., representing 7 community oncology practices across the United States, received an award to implement and test a medical home model of care delivery…. Through comprehensive outpatient oncology care, including extended clinic hours, patient education, team care, medication management, and 24/7 practice access and inpatient care coordination, the medical home model will improve the timeliness and appropriateness of care, reduce unnecessary testing, and reduce avoidable emergency room visits and hospitalizations.”

- From the Centers for Medicare and Medicaid Services

I read with interest a recent article in the Journal of Oncology Practice[1] about Dr. Barbara McAneny of New Mexico Cancer Center and her project to develop a patient-centered medical home (PCMH) model for cancer care. The goal of a PCMH is to improve patients’ experiences and outcomes at a lower cost than what a traditional cancer center spends per patient. The managing company Innovative Oncology Business Solutions (IOBS) has been given $19 million from the Centers for Medicare and Medicaid Services (CMS) and 3 years to create a cost-saving PCMH. IOBS plans to hire 115 new positions in order to implement their goal of saving CMS $33 million over the 3 years-and this is with only seven different oncology practices participating.

The two key expenses targeted by the group are emergency room visits and inpatient hospitalizations, with smaller savings expected from lowering drug usage, by adhering more closely to treatment guidelines, and earlier transitioning of patients to hospice care. In order to achieve these goals, IOBS has established multiple features to “ensure safe, efficient, and high-quality care.”[1] After reading these features I was amazed at how similar their ideas of a medical home are to mine. Could our humble practice be evolving toward the definition of a medical home with zilch for funding?

How arduous is it to transform a typical practice into a community oncology medical home? Let’s compare the characteristics of the ideal community oncology medical home as defined by IOBS with our practice’s current habits.

1. Electronic Health Record? Yes. We have access to both hospital and office records 24 hours a day from anywhere. This is the sine qua non of efficient cancer care, and oh, what fun it is to document every detail for posterity.

2. No Telephone Menu? Yes. Our phones are answered by humans-perhaps too quaint for the 21st century, but crucial to quality (eg, “Press four if you’re vomiting” doesn’t inspire much confidence).

3. Scripted Questions? No. The medical home has their first responders (non-medical personnel) follow scripts for 22 common complaints in order to triage patients and direct them to the appropriate level of care, including empowering nurses to solve problems without checking with the doctor first. We use experienced nurses who do not require scripted questions, but who do consult with me before resolving issues. In the medical home this would be described as nurses NOT working at the top of their license. I get it, and if it weren’t for certain obsessive-compulsive tendencies that I have been accused of having, I would endorse it.

4. Clinical Pathways? Of course! In fact, we make it easy on ourselves and use the National Comprehensive Cancer Network (NCCN) guidelines. Do not forget, however, that scientific breakthroughs outpace the guidelines. Don’t let the bureaucracy pinion you to outdated treatments. Evidence-based medicine means using what works the best, for the best value. Occasionally a patient will require a unique solution.

5. Team-Based Care? Yes. In our practice this is more of an attitude than a structured activity. It is up to me to communicate and collaborate with all of the other professionals caring for a patient, and it must be done every day, all day. The reverse is true for nurses and secretaries, thus the designation “team.”

6. Active Disease Management-what exactly is this? In the medical home, it is disease and treatment education (verbal, written, and electronic), and reserving sessions for discussion, counseling, teaching, medication review, and anything else that comes up. We agree here. Both oncologists and nurses perform this in our practice, with or without scheduling a separate appointment, as we define efficiency as completing the task now, not at the next visit.

7. Enhanced Access? Yes and no. We have 24-hour-a-day call service, and just like a medical home, we insist that our patients come to the office at any time for IV hydration or urgent symptoms, rather than report to the emergency room. We do not, however, offer evening or weekend hours and agree with IOBS that it is hard to motivate the staff to work such hours. We also do not personally manage our patients when they are admitted, but rather use hospitalists and electronic heath records to monitor and assist in care. I confess that I get wobbly in the knees thinking about tacking hours on to the beginning or end of each work day.

8. Enhanced Ancillary Services? Yes. We have an in-house pharmacy and laboratory. Hospital imaging services, however, can be expensive for patients on HMOs who have lower co-pays if they drive to a free-standing center. Funny, though-they don’t mind the inconvenience, and with internet-based radiology we have no difficulty viewing images from either location.

9. Financial Assistance? This was not included as one of the features, but is used constantly in our practice. We provide our patients with medication co-pay assistance information and facilitate their journey through the maze to get their medicine on time and without going bankrupt.

Now comes the hard part, as mentioned in the accompanying commentary to Dr. McAneny’s project.[2] How do we prove that the medical home reduces costs, and is the medical home model expandable throughout the country, to centers both large and small? The task of collecting and interpreting the data for expenditures is a formidable one, with the onus on the center to show how costs have been lowered. No one knows if the medical home will succeed beyond a few pilot practices, but I think it is a major step in the right direction. We believe in its goals and try to follow them every day. Even if our practice cannot produce a spreadsheet for CMS showing how much money we have saved them, we think our patients are getting better care through the medical home philosophy. Ut crescere in virtutibus (May its virtues increase)!

References:

1. Waters TM, Webster JA, Stevens LA, et al. Community Oncology Medical Homes: Physician-Driven Change to Improve Patient Care and Reduce Costs. J Oncol Pract. 2015;11:462-7.

2. Kolodziej M. Oncology Care Delivery Reform: Carpe Diem. J Oncol Pract. 2015;11:468-9.