NcXHF

THE PATIENT-CENTERED MEDICAL HOME
FIGURE 2. Triage System Utilization by (A) Outcome and (B) Time of Triage Call
A
Outcome
911 Call
STAT
Appointment
Same Day
Appointment
Other
Appointment
Follow Up Phone
Call
B
80.00%
60.00%
40.00%
20.00%
0.00%
Time of Triage Call
Office Hours Evening Hours
Weekends
triage, evening/weekend clinic hours, electronic health record
[EHR] access through patient portals and on-call clinicians),
on-site or near-site imaging and laboratory testing,
and admitting physicians who shepherd patients through inpatient
encounters, avoiding handoffs and readmissions, to
ensure seamless, safe, and effıcient care. Further, the COME
HOME program offers physicians and administrators from
community oncology practices unprecedented access to realtime
quality, pathway adherence, and utilization data, including
provider-level measures and benchmarking within
each practice and within the COME HOME Program.
The medical home infrastructure creates four sets of costs
that are not covered under traditional FFS and must be addressed
using an alternative payment model.
1. Medical homes need triage nurses, patient care coordinators,
data analysts, lab technicians, and other staff to
meet the goal of providing the right care at the right time
in the right place. However, most of the services provided
by these staff are not billable under a FFS contract.
2. The medical home relies on leaving daytime physician
time available, thus, running the risk that a valuable
commodity (physician time) will go unused and, therefore,
generate no revenue (opportunity cost).
3. Treating patients with the hydration and symptom control
treatments instead of using the infusion center
overhead for chemotherapy replaces better paying services
with services given at a loss.
4. Offering evening and weekend clinic hours for the infusion
of antibiotics, symptom control medications, and
hydration will keep patients out of the ED and hospital,
but does not generate suffıcient evaluation and management
and infusion codes to cover the salaries of personnel.
During these after-hours clinics, at least two nurses and
associated support staff must be present, but the services
provided, such as hydration and intravenous antibiotics
administration, generate very low reimbursements.
Under the medical home infrastructure as described above,
participating practice sites have shown a 23% to 28% reduction
in the percent of patients with ED visits (Figs. 3 and 4).
Treating patients in a physician’s offıce after hours rather
than sending them to the ED saves payers money, but it actually
costs physicians more money to provide the care than
they are reimbursed. To cover practice costs of a medical
home, the COME HOME program practices will need to enter
into contracts with payers that recognize the value of the
services provided. These services generate savings through
reduced ED and inpatient use, but these savings only accrue
to the payer. We see bundled payments, with options for risk
sharing/shared savings as the best contracting option for sustaining
the medical home infrastructure.
Oncology bundled payments and other risk-sharing arrangements
are highly innovative, untested, and fınancially
risky to physician practices. COME HOME is now beginning
to develop the necessary knowledge base to support bundled
payments/shared savings in this arena. Together with the
COME HOME practices, the team at IOBS has launched two
related efforts to support future oncology bundled payments
with shared savings. First, they are developing a data analytics
infrastructure that will allow for the participating practices
to track improved outcomes, understand their costs for
treating common cancer types (breast, lung, and colon) and
be familiar with sources of savings from the medical home
model to set bundled price targets/shared savings in a transparent
and data-driven way. Second, IOBS is conducting a
series of limited bundled payment pilots with small patient
pools. These pilots allow the participating practices to become
familiar with bundled payment mechanisms while limiting
overall risk. Both of these activities are ongoing at the
moment, and they often inform each other.
FIGURE 3. The COME HOME Beta Site Percent of
Patients with Emergency Department Visits
Run Chart of Active
Patients with ED Visits
50%
Baseline
40%
30%
20%
10%
0%
1
2
3
4
COME HOME Quarter
The COME HOME beta site shows a 23% reduction in the percent of patients with
emergency department visits.
5
6
asco.org/edbook | 2015 ASCO EDUCATIONAL BOOK
e85