Effective EHRs, supportive leadership, and robust physician-patient communication are key elements to successful implementation of the Center for Medicare & Medicaid Services’ Oncology Care Model (OCM), according to a summary of experiences published in the Journal of the National Cancer Institute.
Lead author Ronald M. Kline, MD, of the Center for Medicare and Medicaid Innovation and colleagues interviewed three practices and one network of practices that have employed the agency’s OCM, which uses an episode-based payment structure and aims to enhance care quality, boost high-value care, and reduce costs. The model uses a two-part payment approach, which includes monthly care management payments and potential retrospective, performance-based payments based on lowering episodes’ total cost of care. Institutions interviewed for the summary were the Clearview Cancer Institute, based in Huntsville, Ala.; the Lancaster General Medical Group, based in Lancaster, Pa.; the University of Texas, Dallas; and the U.S. Oncology Network – McKesson Specialty Health, which operates across 25 states. Representatives from each institution answered questions about their successes and challenges with the model, including how the OCM has impacted work flow and patient care.
A central theme that emerged during the interviews was the importance of communication improvements among health care teams and within patient relationships to effectively implement OCM. For example, the Clearview Cancer Institute reported that, from the top down, communication has been a key factor in transforming patient care under the model. Weekly and monthly feedback reports for Clearview clinical employees paired with active efforts to improve communications between administrative and clinical staff have boosted collaboration among teams and ensured that OCM requirements are met, according to the interview summary. As part of OCM, participants must enact certain communication enhancements, including physician-patient discussion of treatment risks and goals through structured communications, such as the Institute of Medicine (IOM) Care Management Plan. Clearview officials reported that, before model implementation, about 2% of its patients had their advance care status documented in the EHR, compared with more than 90% of patients who now have such information documented.
For the Lancaster General Medical Group, revamping how and what type of information was documented in its EHR vastly improved its practice work flow and allowed staff to make more informed decisions as part of its OCM efforts. For example, the model’s requirement for the IOM care plan inspired Lancaster leaders to redesign its informed consent process with a sharper focus on shared decision making, advance care planning, and anticancer treatment education for patients, according to the summary. Lancaster also changed its process for starting an office visit in its EHR so that physicians and staff must review or perform important care management tasks associated with OCM implementation. The “rooming tool” developed for this goal became so beneficial that Lancaster’s EHR vendor will soon be making the tool available nationally.
However, for the University of Texas, Dallas, technology deficiencies within its EHR have posed challenges for instituting elements of the OCM. Program administrators underestimated the effort required to tailor systems to meet OCM metrics across its two participating institutions, university officials reported in the summary. A number of key activities required for OCM transformation have been delayed as the institution attempts to align work flows with its technology, including harmonization of triage scripts, mechanisms of nurse triage documentation, consistent use of staging and oncology history modules, and implementation of a clinical pathways program. Efficient use of technology remains the university’s biggest challenge to the model, according to program administrators.
Meanwhile, the U.S. Oncology Network emphasized the value of designating physician leaders responsible for driving change at each of its OCM-participating sites. Network officials reported that physician champions at each site share information about OCM claims data with colleagues and identify opportunities for improvement. For example, data regarding outliers in hospitalization rates, ED visits, treatment plans, quality metric documentation, and advance care planning. U.S. Oncology Network leaders stressed that OCM program success cannot be achieved without strong physician leadership and engagement.
Dr. Kline and colleagues concluded that there is not a single path to patient-centered, high-value care, writing that the CMS made OCM flexible so that practices may discover their own paths to practice transformation.
“Regardless of structure, however, participation in OCM and other similar value-based models is an acknowledgment of anticipated future health system changes in the U.S. and a desire to gain experience in this new paradigm earlier in the process,” Dr. Kline wrote in the summary. “As these practices have described, the path is sometimes challenging, but is intended to ultimately lead to improved patient engagement and care.”
CMS’ Oncology Care Model started in July 2016 and the performance period ends in June 2021. Participants include 176 practices and 10 payers. For more information on the model, visit the CMS website.
Two coauthors are employees of CMS. Other coauthors are employees or partners in OCM practices or their management companies, which receive payments from CMS for their participation in OCM.
SOURCE: Kline RM et al. J Natl Cancer Inst. 2019 May 3. doi: 10.1093/jnci/djz072.