Nov 05, 2019
By Rachel Martin, ASCO Communications
In northeastern Montana, just over the border from North Dakota, the sky stretches long and wide over sparse prairieland dotted by tiny towns. Patients with cancer who live in the region must travel up to 2 hours for treatment at Sidney Health Care, the only available cancer center in this medically underserved corner of the country. It’s a 4-hour drive—often made more difficult by hazardous weather conditions—to larger health care facilities. Up until 2 years ago, patients with cancer in the Sidney region would see an oncologist who flew in twice a month from the Billings Clinic.
Sidney Health Care now has a dedicated radiation oncologist, a few nurses, and no advanced practice providers (APPs). “For medical oncology, it’s just me,” says Chad Pedersen, MD, who joined the practice 2 years ago. Around that time, Sidney Health Care started a capital campaign to expand its cancer care program.
“We’d had tremendous growth, we were building a clinic, and we had to find ways to deal with increasing demand. It affected the whole hospital and there were a lot of questions about how to make this work,” said Dr. Pedersen. “Coming from a fellowship program, I knew what a well-run, world-class cancer program looked like. But how do we make that work in a very small, very rural hospital?”
Oncology practices—from the very small to the very large and everything in between—all aim to provide high-quality care for every single patient who walks through their doors. However, massive shifts in the health care landscape, prompted in large part by the transition to value-based care, are creating new challenges and exacerbating existing pressures throughout the oncology ecosystem.
New administrative hurdles, including burdensome payer requirements and increased quality and financial data reporting, are weighing heavily on practices. Shrinking margins are intensifying the stress of financial and competitive pressures, making it more important than ever for oncology practices to operate efficiently.
“We are in an era now where we are being asked to do more and more with less and less,” said Stephen Grubbs, MD, FASCO, vice president of Clinical Affairs at ASCO. ASCO has made a commitment to help physician leaders and other oncology care team members navigate the turbulence in the cancer care delivery system and improve the health of oncology practices to ensure their capacity to provide high-quality, high-value cancer care to patients. “As the health care system moves ahead in fits and spurts, all of us have to learn how to adjust and transform to make sure we are successful in this system in order to provide the best possible patient care,” said Dr. Grubbs.
Improving Fragmentation and Striving for Quality
Dr. Pedersen reached out to ASCO for guidance in transforming a small outreach clinic into a world-class cancer care center that could withstand the changes occurring in the cancer delivery system nationwide while continuing to grow its services in order to make sure that every patient gets needed care.
Elaine Towle and Ronda Bowman, two members of ASCO’s Consulting Services team, flew to Sidney and met with Dr. Pedersen and other members of the cancer care team to figure out some of the biggest obstacles. One priority for Dr. Pedersen was addressing fragmentation of care.
“It’s not unusual for a woman diagnosed with breast cancer to have an abnormal mammogram in one facility, biopsy in another facility, pathology in another institution, surgery at another institution, and then reconstructive surgery with a different group. Her primary care physician may not be affiliated with any of these other entities. And then she sees me,” he said.
With ASCO’s help, Dr. Pedersen and his team started an extensive effort to gather complete patient records from across the multidisciplinary cancer care team to ensure they knew each patient’s full story. They also made major changes to the way they retain records. Now, with access to all of the information they need about a patient’s journey, clinicians are better informed before recommending next steps in treatment.
Sidney Health Care also worked to improve training and education for its clinical staff. “We had very skilled nurses who had been here for years, but had no oncology experience,” said Dr. Pedersen. “ASCO was tremendous in providing us tools specific for oncology, best practices, advanced practitioner recruitment guidance, onboarding tools, clinical workflows.” The center now has a well-established onboarding process that is used with everyone working on the cancer care team. They’re actively working to hire an APP, despite recruitment challenges inherent in attracting experienced professionals to a rural area like Sidney.
Dr. Pedersen is focused on one other goal: ASCO Quality Oncology Practice Initiative (QOPI®) Certification, which aims to create a culture of excellence and self-examination that helps practices deliver the best care to their patients. The practice is currently going through the certification process, addressing issues like improving patient adherence to oral chemotherapy and creating triage protocols.
“Being a small center, I want to be sure that we’re doing things right, and QOPI Certification is one way to make sure we are. QOPI Certification is a big deal for a practice like ours,” he said.
Turning Five Silos Into One Efficient Practice
A few hundred miles southwest of Sidney, Bozeman Health Cancer Center has encountered its own challenges as they address disruption in the cancer care delivery space and their own regional changes. Over the past few years, Bozeman Health Cancer Center has seen a steady increase of patients come through their doors. Their south-central Montana region was experiencing rapid growth, and positive word-of-mouth about the cancer center led to an increase in new patients.
“There used to be a perception that you had to go to Billings to get cancer care. I came from an academic background, and I knew that we were capable of delivering good care, so I worked hard with cancer support communities to get out the word that we could take care of you here,” said Jack O. Hensold, MD, the Bozeman Health Cancer Center Clinic physician leader.
As their clinical staff and patient population grew, Bozeman Health’s services continued to expand, and the practice started to feel some growing pains. After talking to ASCO’s Consulting Services team, they decided that they needed to do a major restructuring of the cancer center.
“We were in a pod system where every physician had their own APP, their own scheduler, their own nurse, and their own medical assistants,” said Jo May, the cancer center manager. Dr. Hensold added, “One of the comments that the ASCO consultants made is that we were basically running five solo practices. The insular nature of those practices was really affecting culture in the office and standardization of care. It did not allow for best practices to be shared or worst practices to be recognized.”
Bozeman Health undertook a 7-month effort to change the entire structure of their practice. Instead of silos, the oncologists and other clinicians moved into a full team-based structure with standardized practices.
According to Dr. Grubbs, workforce issues are at the heart of nearly every practice health issue. Especially in today’s world of value-based care, a workforce that isn’t operating efficiently or working at their highest level can impact the financial sustainability of the practice and the quality of patient care.
“A healthy practice has every role well defined, working to the highest level—which, by the way, also leads to job satisfaction and mitigates burnout,” said Dr. Grubbs. “Every single person that operates within the practice—starting with the greeter at the front desk, through the financial portion of the office, through scheduling, to nursing and the full care team and beyond—has a role to play in ensuring the best possible outcome for the patients and their families. Everyone is involved and needs to know that they are involved.”
As part of its staff restructuring initiative, Bozeman Health Cancer Center created a communications committee (made up of two physicians, two nurse practitioners, and a nurse) that was tasked with finding a way to streamline communications among the clinical staff. The practice established standardized notes and set up a twice-daily huddle where APPs and physicians meet to review patients being seen that day.
While the restructuring just went into effect this summer, the practice is already seeing increased efficiencies. For example, in the old system, physicians were each assigned one APP. If that person’s schedule was full, physicians weren’t able to schedule appointments for additional patients—even if other APPs were available. Now, physicians can work with any of the practice’s APPs, which has allowed them to bring in more patients.
“Our new team model helps provide more access to our patients,” said Whitney Pritham, APRN, CNP, an APP at Bozeman Health Cancer Center.
“It’s working well, but it has increased the amount of chocolate I need to bring in to keep APPs happy,” Dr. Hensold joked.
The new team-based structure has also allowed for increased standardization across the oncology practice. They started off by standardizing the tasks assigned to medical assistants so that each person did things the same way. They’ve also taken steps to standardize the notes in their electronic health records so that everyone who adds to patient records includes the same type of information in them.
“Standardization of what we do is important for safety, but it’s also important to ensure quality. These attempts to standardize lead us all into conversations about best practices. It forces the discussion that we weren’t having before,” Dr. Hensold said.
“It’s nice for us to learn from other doctors, share practices, and expand our knowledge that way,” Ms. Pritham added.
The practice is continuing to look ahead to see how they can continue to improve efficiencies and deliver the highest quality patient care. “We knew we were delivering high-quality care, but we had no way to figure out how to express it. We decided to bring in QOPI standards and create our own quality committee within the group to make sure the [restructuring] changes didn’t create any new problems and address any issues that arose,” Dr. Hensold said.
“We feel like we’re much more efficient and communicating better. We may not be perfect at it yet, but we’re making progress. ASCO introduced all of these possible solutions and we’re integrating them into our cancer center and seeing what works for everyone here,” said Ms. Pritham.
Harnessing Data to Make Changes in Oncology Practice
Over the past decade, practices have gained access to new sources of data on their performance, both in terms of quality and financial metrics. But the vast array of data available can sometimes be overwhelming for practices to sort through. The data is complex, and without time and tools to understand, analyze, and interpret the data, it can be hard to determine how to respond.
Michelle Brown, the chief operations officer at the Clearview Cancer Institute in northern Alabama, had been looking for a way to better benchmark her center’s performance to other oncology practices across the country. They were looking for details on key metrics, from readmission rates to biosimilar usage to number of full-time clinicians and office staff, in support of their transformation from fee-for-service to value-based payment.
One of the primary issues of concern for Clearview was the substantial increase in prior authorization requests they were receiving. They’re not alone: according to the American Medical Association’s 2016 Prior Authorization Physician Survey, practices spent an average of 16.4 hours a week handling prior authorizations. Ms. Brown felt that they needed additional staff to process these prior authorization requests and ensure patients’ regimens were approved quickly so that patients didn’t have to wait to start treatment.
Clearview was able to look at the data from ASCO’s PracticeNET program and see that they employed fewer business staff than practices of similar size. “We were able to make physicians understand that, nationally, we were low in the business office area compared to where others are,” Ms. Brown said. “It helped us prove to our physicians that this really brought value.”
Based on this data, the center hired one additional business staff member to work on prior authorization requests. Prior to bringing on additional staff, the cancer center had a turnaround time of 4 to 5 days; today, requests are typically approved in under 48 hours.
“Previously, prior authorizations were done on the payer’s portal. We did not have the staff to spend on the phone with peer-to-peer reviews for approvals. With the additional staff members, we can get approvals much faster by picking up the phone and speaking with someone instead of going through the portal,” Ms. Brown said. The cancer center also brought on a nurse to work with the business team and handle peer-to-peer consultations, which led to a 50% reduction in peer-to-peer requests for their physicians.
Clearview is one of nearly 200 practices in the United States participating in the Oncology Care Model (OCM), an oncology-specific Advanced Alternative Payment Model that is currently being piloted by the Centers for Medicare & Medicaid Services (CMS) through 2021. Under OCM, practices commit to providing enhanced services to Medicare beneficiaries (such as care coordination and patient navigation), decreasing emergency room (ER) utilization, and using national treatment guidelines for cancer care. In turn, CMS supplies practice feedback data so that practices can see how they’re doing. According to Ms. Brown, the OCM pilot program is going well for Clearview, and they’re interested in working with other payers to implement similar models.
ASCO PracticeNET recently added new capabilities to allow benchmarking for practices participating in the OCM, providing Clearview with quality and utilization benchmarks from other OCM practices.
By looking at the OCM-focused data within PracticeNET, Clearview realized they could be performing better on hospice use and end-of-life care for patients. In response, they have been working on an in-house supportive care program focused on palliative care and early hospice use to not only improve their metrics in OCM, but also reduce cost of care and, most importantly, improve patient care and satisfaction.
On the flip side, staff and practitioners at Clearview have also had the opportunity to see where their practice was performing particularly well.
“We found that what we’re doing on ER use is really working,” Ms. Brown said. Their call-first program and nursing triage has helped keep their ER utilization down and their readmission rates steady.
“We’re able to reinforce with staff and physicians that what we’re doing is really working and to give them kudos,” said Anne Marie Rainey, MSN, RN, CHC, compliance and quality control officer at Clearview Cancer Institute. “It’s easy for us to say, ‘Keep doing what you’re doing, because it is working.’ We always look forward to getting our PracticeNET data to see how we’ve done over the past quarter. It’s exciting because now we understand it and can actually apply it.”
Continual Quality Improvement in Cancer Care
Today, every medical practice that accepts Medicare patients needs to report on quality, and if practices fail to meet quality metrics, it takes a toll on their reimbursement. “If people weren’t paying attention to quality before, they certainly are now,” said Dr. Grubbs.
Ephraim Casper, MD, a physician leader at Valley-Mount Sinai Comprehensive Cancer Care, a large practice in Paramus, New Jersey, 15 minutes from New York City, has been focused on quality throughout his entire career. He came to Valley-Mount Sinai 3 years ago from Memorial Sloan Kettering Cancer Center. “It was very clear that people at Valley were absolutely committed to quality and saw that as a core,” he said.
However, like many oncology practices, he found that measuring quality of care was difficult. “There are many measures that are out there—whether established by government agencies or outside payers—but particularly in oncology, there’s a frustration that things that people were calling ‘quality’ had little to do with the quality of oncologic care,” said Dr. Casper.
To get a better handle on their quality performance metrics, Dr. Casper and his team worked with ASCO to go through the QOPI Certification process. “What we learned is that we do practice in an evidence-based, reasonably consistent way,” Dr. Casper said.
Through a 32-plus month journey toward QOPI Certification, Valley-Mount Sinai primarily focused on “tightening up the way we do things,” Dr. Casper said. They found that they delivered cancer care at a very high level, but there was room to improve some of the processes that they use. For example, to address the issues of chemotherapy administration and oral therapy education, they hired an oncology nurse specialist who created a rigorous education checklist program to ensure that staff were aware of and paying close attention to critical issues including safe handling, documentation, and patient education.
“One of the things that I find rewarding is that it’s beyond just checking a box. Checkboxes are important, but things need to make sense, and they need to make sense for our patients,” said Sobeida Santana-Joseph, RN.
Valley Health also hired a fellowship-trained palliative care physician, who was integrated into the care of patients early on. Initially, “I thought that it wasn’t really working. But then she needed to be away for several months. My colleagues came to me asking, ‘When is she coming back? We really need her, and the patients need her,’” Dr. Casper said.
The medical oncologists found that the palliative care physician provided a different perspective on patient needs that weren’t typically reflected in an oncologist’s notes and filled a gap that they hadn’t known was missing. “All of that has made our practice better, safer, and patient satisfaction has increased. And I think that provider burnout has decreased,” said Dr. Casper.
Cancer research has delivered new evidence and a plethora of new treatment options that offer many patients hope and better outcomes. However, it has also made it more difficult for oncologists to keep up with the pace of new research and treatment guidelines. To more fully integrate the rapidly emerging knowledge and continue to deliver the highest-quality patient care, Valley-Mount Sinai’s oncology practice has evolved to become disease specific. “We have a breast cancer team, a lung cancer team, we have a genitourinary team, we have a brain cancer team, we have a gastrointestinal team… We run 11 disease-specific tumor boards that meet between once a week to once every month or two to discuss cases,” Dr. Casper said. This specialization allows each oncologist to focus on the new research and developments specific to their cancer. The practice has also started using a clinical pathways program to ensure that providers are consistently delivering quality care to patients.
Valley-Mount Sinai is also looking forward to their QOPI Certification, but Ms. Santana-Joseph says that certification is just one benefit of the program: “QOPI Certification is not a destination or an endpoint. It is a journey that cultivates a culture that focuses on quality, high reliability, and patient safety.”
“When you stop thinking that you don’t have to get better, it’s time to hang it up,” Dr. Casper concluded.