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Hematologists Are Told to Get Ready for ACOs

A Medical Home May Be a Viable Alternative
February 2012 Vol 5, No 1, Special Issue

Accountable care organizations (ACOs) are the new model of care that has generated a buzz in the industry, but their role in hematology and oncology practices remains unclear. “They’re like unicorns,” said Lawrence A. Solberg, Jr, MD, PhD, of the Mayo Clinic, Jacksonville, FL. “We have an idea of what they’re supposed to look like, we’ve read about them, but I’ve yet to meet a hematologist who’s actually seen one.”

The healthcare reform focuses on the formation of ACOs as key to transforming the current fee-for-service business model to a model in which provider groups will receive bundled payments, based on measures of the quality and value of care.

Dr Solberg moderated a Practice Forum panel at ASH 2011, titled “How to Prepare Your Practice for ACOs and Other Payment and Health Reforms.”

The Options for Hematologists
“The take-home is this,” said panel member Neil M. Barth, MD, FACP, Newport Pacific Medical Associates, Newport Beach, CA. “Going forward, to satisfy the needs or the reform legislation, efficiencies must be achieved, delivery systems must be integrated, overall utilization must be reduced, and new payment models must be employed.”

The goal of the patient-centered model of care is to improve outcomes at a lower cost. To achieve this, Dr Barth sees several options.

Remaining an independent subspecialty provider. The first option is to do nothing: “If you choose to maintain the status quo, be locked into a small practice size, and be fiercely independent, you’re probably going to be eaten alive,” warns Dr Barth.

At least based on his experience in California, the writing is on the wall, Dr Barth said. Not only is there a general decrease in reimbursement, but there is also “narrow network pressure,” whereby providers who have high costs are being dropped by payers and are losing their preferred provider status.

“It started out quietly, but this practice is no longer subtle,” said Dr Barth. The message is clear: when it comes to cost cutting, an individual cannot compete with a group.

Becoming a subspecialty line consultant. The second option is becoming a consultancy. “This is the extreme makeover for the practicing hematologist,” Dr Barth noted. Under this option, the hematologist identifies strengths and services to be offered to the local healthcare system.

“This will require capitalization on service line knowledge. You have to study and to dissect the service line you would manage,” Dr Barth advised. Some skills may have to be brought in to round out a consultancy package, such as actuaries or an MBA degree.

The third option is clinically integrated groups, including ACOs. “This is a legal structure of individuals or even a corporation of corporations; but however it’s configured, the glue holding it all together is IT [information technology].”

“Integration” means the ability to share medical records, allocate re­source utilization, and perform cost accounting. “One of the attractive things about this is, most of my colleagues are fiercely independent,” said Dr Barth. “Doing it this way you do not have to give up financial sovereignty, because you’re not under a common tax ID number.”

This model is outside the ACO structure as proposed, but according to Dr Barth, with the blessing of the Federal Trade Commission, it can be done, and such an entity may engage in collective bargaining.

Joining/creating a clinically integrated ACO. ACOs are integrated groups under a financial umbrella, yet cannot be well defined. “If you’ve seen one, you’ve seen one,” Dr Barth said, “and most of us have not seen any. Frankly, we’re not sure how this is going to play out.”

Healthcare reform legislation is still in flux, and ACOs, initially designed with the primary care provider in mind, remain to be tailored for the hematologist. The final rules for ACOs were issued in October 2011, and certain changes have been made, including:

  • The Centers for Medicare & Med­icaid Services will annually update ACO patient risk scores
  • “Meaningful use” for electronic health re­cords is no longer a prerequisite
  • Start-up funding will be available for physician-group–only ACOs
  • There is no longer a downside risk in track 1
  • The number of quality measures has been reduced from 63 to 33.

Joining a medical foundation. The fourth option for hematologists is joining medical foundations, which are already well integrated and represent the path of least risk and resis­tance, if available.

In addition, Dr Barth stressed the need for integrated IT in any type of practice. “It’s the essential part that helps any of these structures come to fruition.” Systems are going to need standardization to store and then share medical records. Evidence-based guide­lines must be part of the integration. Algorithms are needed to track performance metrics, and the results will have to be delivered in real time so that providers can compare the results against the agreed-on benchmarks.

The Medical Home Gets Results
The definition of a patient-centered medical home (PCMH) varies, but in general the medical home model promotes a team-based approach to patient care through a spectrum of disease states and across various stages of life. Care is led by the patient’s personal physician, with the patient serving as the focal point of all medical activity.

“Applying this model to oncology is what we have been working on for the last several years,” said John D. Sprandio, MD, Chief of Medical Oncol­ogy and Hematology at Delaware County Memorial Hospital, Drexel Hill, PA. “Ours was the first in the country to be recognized as a level III patient-centered medical home by the National Committee for Quality As­surance in 2010.”

Dr Sprandio’s PCMH is responsible for coordinating all oncology services. A primary care provider addresses nononcologic issues, but everyone—surgeons, radiation oncologists, and even hospice staff—is in “intense” communication as part of the overall care unit.

Dr Sprandio described the goals for each aspect of the PCMH:

  • A team approach that fosters collaboration within the team to assure adherence to treatment guidelines, proactive management of adverse events, palliative care coordination, participation in clinical trials, and active engagement with the patient to develop patient-directed therapeutic goals
  • The merger of operational and clinical decisions, which include standardization of patient assessments, patient tracking, telephone triage of patients, and patient IT portals (for appointments, etc)
  • Quality standards, including treating according to guidelines, pro­active symptom management, co­ordinated end-of-life care (shared decision-making), and the creation of high-risk registries
  • Outcomes can be derived from tools such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS). “We use the CAHPS surveys,” Dr Sprandio said. “It’s a wonderful tool for looking at the actual delivery of care.”

Dr Sprandio shared his experience with the integrated PCMH from 2004 to 2010. “The effects have been substantial in terms of emergency room utilization per patient per year, as well as hospital admissions.” There were 2.6 emergency department visits per patient in 2004, and only 1 visit per patient in 2010; hospital admissions decreased from 1 per patient in 2004 to 6 per patient in 2010.

There was a 23% increase in hospice stays, with 70% of patients in 2010 dying in their own homes. In addition, they had a 40% reduction in the number of admissions in the last 30 days of life and 23% fewer evaluations in the emergency department.

The cost-savings generated by these reductions in utilization were substantial. Dr Sprandio estimates savings of $8.8 million in hospital admissions, $660,000 in emergency department visits, and $12,000 in chemotherapy-related costs per patient. “Calculated per provider, our hematologists are saving about $1 million a year,” he said.

He advised hematologists to:

  • Define your clinical and financial goals
  • Secure a buy-in from providers (make it clear to them how your integration will be done)
  • Engage payers
  • Standardize all processes of care
  • Overall, commit to continuous pro­cess improvement.

The panelists conceded that questions regarding the ideal model remain and uncertainty regarding ACOs abounds, especially with regard to hematology/oncology practices.

Last modified: August 30, 2021