The Patient Centered Medical Home in Oncology
Practical Considerations in Specialty ACOs
April 27, 2014
Jeff Patton, MD & Wes Chapman
Preface: This is the first in a series of articles highlighting practical observations from our team’s efforts to build a Patient Centered Medical Home (PCMH) integrated into a private accountable care organization (ACO).
Home Sweet (Medical) Home
Patent Centered Medical Homes – A concept a long time in development
The American Academy of Pediatrics introduced the concept of a patient centered medical home in 1967, and it was first tried in practice in scale in Hawaii in the 1980s by Dr. Calvin C.J. Sia, a Honolulu-based pediatrician. By the late ‘90s a number of family medicine organizations adopted the concept, and by 2004 there were a large number of PCMH pilot programs initiated throughout the US – all focused on primary care. Some of the early programs set the stage for extremely ambitious PCMH objectives, including, “The services should be accessible, accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians.”
Like so many good ideas, the PCMH suffered immediately from scope creep and inflated expectations. Promoters of the concept of the PCMH in this period (middle 2000s) forecast that the PCMH would result in large reductions in costs (over 5% of total US healthcare costs) coupled with documented improvements in quality. This is an awful lot to ask of a juvenile care delivery model, and one in which the primary care physicians were shouldering an increasingly large responsibility for management – often of specialties in which they had no training and limited time or resources.
By 2005, the American College of Physicians had developed an “advanced medical home” model. The model involved the use of evidence-based medicine, clinical decision support tools, the Wagner Chronic Care Model, medical care plans, “enhanced and convenient” access to care, quantitative indicators of quality, health information technology, and feedback on performance. Payment reform was recognized as important to implement the model but was supported in fits and starts by CMS and private payers in a variety of bundled payment and population based shared savings models via ACOs. By 2011 and the publication of “Guidelines for Patient-Centered Medical Home (PCMH) Recognition and Accreditation Programs”, the PCMH had developed into an overly broad and potentially unwieldy concept.
The result has been a wide variety of idiosyncratic paired ACO/PCMH models, each somewhat unique custom tailored to “pre-existing conditions” in the markets served, the interaction of the payer/physician/hospital/regulatory groups in the local environments, and finally the nature and capabilities of the EMR and related electronic interfaces. Not too surprisingly, the success of these various models has been mixed as pointed out in a February JAMA article, “Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care”.
In a related JAMA editorial highlighted the tenuous credibility of the PCMH as a panacea, “The PCMH involves a deceptively simple set of key structural practice features that have been proposed to result in enhanced access for routine primary care, improved delivery of preventive services, high-quality chronic disease management, and reduced emergency department and hospital utilization…Advocates for the PCMH may be disappointed by the results of the study by Friedberg et al reported in this issue of JAMA. They need not be disappointed, but they should pay close attention to the study’s lessons.”
In short, these structures can work – but you need to do it right.
How to make the PCMH valuable in Medical Oncology
First, why develop a special medical home for cancer patients who may already be included in a primary care medical home? Cancer is an acute condition that involves very large commitment of highly specialized treatment. These treatments are very difficult to coordinate, and produce side effects which are frequently debilitating, and can be life threatening in their own right. Balancing these treatments with the needs of the patient requires a large dedication of resources, highly specialized knowledge, and intimate involvement with the patient treatment plan. Primary care medical homes are simply not equipped to deal with the needs of cancer patients.
We are focused on the development of a very light weight structure for the development of PCMHs in oncology, built on the existing care delivery systems – which are already extensive and expensive. Specifically we are concentrating on activities which support 4 key objectives:
- Transparency & Education: meaning the free availability of the key information needed by all parties – patients and their families, the entire medical (and Pharma) team and the payers – to make timely and informed decisions.
- Planning: every activity undertaken is done as part of a clear and transparent plan open to all for comment and revision as circumstances dictate. Plans are based on best practice and evidence, and are designed around the accomplishment of the patient’s realistic life goals.
- Elimination of Waste: nobody benefits from waste in the care delivery system. It burdens the entire system and ultimately benefits no one.
- Teamwork/Communication: every patient is at the center of a defined team, with the medical oncologist acting as QB. The team has both regular and event driven lines of communication. Every member of the team – including the patient – has responsibilities, and the success of the team depends on all of the members.
We are currently focused on 4 key process areas to accomplish these objectives:
- Pathways: pathways normally refers to the selection of NCCN compliant pathways which always include drug therapy, but may also include surgery, radiation oncology, diagnostic radiology and testing – particularly genetic biomarker testing. Pathways can be developed and maintained internally, and are also widely available from a variety of vendors – we are partial to the system available through Via Oncology, but there are many others available that do a good job as well.
- Care Plans: care plans are fundamental to transparency, planning and teamwork/communication. At the outset we are trying to limit the scope of care plans to the reasonable scope of care directed and administered by the medical oncologist.
- Patient Management: cancer patients have extremely complex treatment requirements associated with the side-effects of the care that they receive. These can be tremendously unpleasant, and vary between individuals. A key objective of patient management is controlling the care associated with these side-effects – which both improves care and tremendously reduces waste.
- Palliation: means symptom management and patient comfort. Palliation is a concept that needs to be an integral part of patient care from the first visit onwards, and is completely relevant whether the objective of care is curative or supportive.
Finally, it is worth taking a brief look at the issue of accreditation and credentialing. There are now five major groups providing accreditation for PCMHs according to MGMA, including NCQA, AAAHC, AAFP, TJC and URAC. There are also some very promising efforts coming forth from the ACS CoC with oncology specific medical homes. At this time, however, the Patient Centered Specialty Practice (PCSP) through NCQA is the closest thing to our needs, and is the accreditation that we are seeking first.
The design and implementation of a PCMH is a key first step in our process, but will inevitably fail unless integrated with payment reform designed to align the interests of all of the medical home participants. We will take a look at some of the key considerations in alignment, quality and payment reform in our next article.