Abstract: Clearview Cancer Institute is a private, community practice participating in the Oncology Care Model (OCM), an innovative pilot project sponsored by the Centers for Medicare and Medicaid Innovation. Through implementing processes set forth by OCM practice requirements and analyzing beneficiary claims data made available through participation in the program, Clearview Cancer Institute has successfully identified eligible patients, completed required documentation points, and increased awareness and outcomes for patients related to depression screening, hospitalizations, emergency room use, and hospice use. The practice continues to refine processes for nurse navigator triage pathways and clinical pathway compliance and tracking to improve processes and patient care outcomes. A review of new programming and program modifications implemented to enhance current programming at the practice is provided. Successes and challenges during implementation of the OCM are discussed. A subsequent article will compile and analyze more comprehensive data from the program and what that data means for the future.
Acknowledgments: Thank you to the team at Clearview Cancer Institute for their dedication to patient care and outcomes, which have made this article possible.
The Oncology Care Model (OCM) is an innovative, specialty model created through the Center for Medicare and Medicaid Innovation (CMMI), a division of the Centers for Medicare & Medicaid Services (CMS). Under this model, practices and payers enter into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients. The program seeks to “provide higher quality, more highly coordinated oncology care at the same or lower cost to Medicare.”1 It aims to accomplish this through aligned financial incentives (performance-based payments [PBPs]) and by helping practices enhance their care delivery with optimized patient navigation and improved access; reduction of avoidable emergency department visits; improved advance care planning; and improved psychosocial support.2
When the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law, it made strides in transforming the current fee-for-service Medicare system into a value-based, pay-for-performance system that rewards providers for better care instead of more services. MACRA created tracks for reimbursement: one track combines parts of the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VBM), and the Medicare Electronic Health Record incentive program, creating the Merit-Based Incentive Payment System (MIPS); the other track is the Advanced Alternative Payment Models (APMs) option.
The OCM is one of CMS’s advanced APMs that involves 2-sided risk. Participating practices will continue to be reimbursed through Medicare fee-for-service, but this is incorporated into the OCM 2-part payment approach: Monthly Enhanced Oncology Services (MEOS) and PBPs. The MEOS payment is a $160 per member, per month payment for each 6-month episode. OCM practices are allowed to bill this fee for patients meeting eligibility criteria (eg, Medicare as the primary payer paired with a qualifying cancer diagnosis and chemotherapy initiation) for which the practice provides enhanced services, as listed in Box 1. The PBP is a bonus payment that is derived based on a complex methodology, taking into account savings to the Medicare program and quality metric performance, among other factors.3 Physicians who receive a percentage of payments through OCM are then exempt from MIPS adjustments and are eligible for other incentives. Practices electing 1-sided risk in the OCM program are considered a partially qualifying advanced APM and are still required to report Advancing Care Information (ACI) to the MIPS program. All other aspects of the MIPS program (including quality, cost, and improvement activities) are fulfilled through OCM participation.4 If a practice elects 2-sided risk in the OCM program, the practice becomes an advanced APM and is no longer required to report on ACI measures. Depending on performance, the practice may become eligible for a 5% bonus on specified services.3
In order to participate, practices must meet certain requirements (Box 1), one of which includes implementation of the Institute for Medicine Care (IOM) 13-point care management plan.5,6 Oncology practices were invited to submit an application for participation that would impact Medicare beneficiaries and any private payers that intended to participate in the model alongside CMS.
Since 1985, Clearview Cancer Institute (CCI), has served hematology and oncology patients across north Alabama. CCI is a private, physician-owned, community practice with 3 full-service locations and 3 satellite clinics and is home to 14 physicians and 17 advance practice providers. At the full-service locations, CCI offers outpatient therapy, diagnostic imaging, genetic and genomic testing and counseling, lung cancer screenings, a specialty pharmacy, autologous stem cell transplant, physical therapy, and clinical trials, including phase 1 trials.
CCI became aware of the OCM program in early 2015, and there was immediate interest in applying for participation. The OCM was attractive to CCI for several reasons. The first was that CCI met the practice requirements with the exception of the 13-point IOM care management plan. Another reason included the MEOS payments to help supplement the hiring of staff, new technology implementation, and assistance with data analytics. An additional consideration was the comparison of CCI’s practice characteristics, data, and patient population to other oncology and hematology practices. This comparison information was a strong motivator for physician leadership and was one of the major complaints surrounding previous years’ participation in the PQRS. The receipt of the Quality Resource Utilization Report each year solidified the need for comparison to specialists in oncology and hematology.
This article details CCI’s experience in applying and preparing for OCM participation, including identification of care delivery areas in need of alterations or new programming, how these enhancements were achieved, and challenges encountered throughout the process. The aim of this article is to provide practice enhancement strategies through communication of CCI’s experiences and subsequent lessons learned to aid other practices on the same journey.
A subsequent article will provide an expanded discussion of these items along with comprehensive data to inform on practice success thus far.
A discussion on methods ensues on the next page
Methods
The application process for the OCM program took several months. A request for applications was released in February of 2015. Letters of intent were required to be submitted by interested practices by May 7, 2015. Following this, there were several learning opportunities provided by CMMI for practices to gain more information about the program and application process. The application itself was due June 30, 2015 and required information about practice demographics, location, payer mix, and feedback surrounding OCM program development at that time. In addition to the standard application, practices were required to submit several narratives, including an implementation plan, financial plan, diverse populations narrative, and letters of support from any commercial payers that were interested in OCM partnerships.6
During the application process, participants of the OCM program were guaranteed receipt of historical Medicare claims data from 2012 to 2015. Additionally, OCM practices were also informed they would be provided with raw claims data as well as a feedback report each quarter during participation. This feedback would provide comparisons with other oncology practices, both those participating and not participating in OCM.7
The process for completing the application allowed our practice to truly assess the services we were offering as well as identify deficiencies in areas where we could improve care for our patients. Leading up to acceptance in the program, CCI began investigating processes for tracking proposed quality measures, preparing for the potential addition of new clinical staff members, and considering billing options surrounding MEOS payments. Because there was uncertainty surrounding acceptance into the program, many steps around education and new program implementation were not put into place until notification of acceptance.
Developing a Framework for Practice Changes
CCI was notified of acceptance to the model in April 2016, with the model start date set for July 1, 2016.
CCI created an internal OCM team to assist with activities related to the model. The team includes a physician champion, a business office representative, the compliance and quality control department, and the chief operations officer. Additional employees and administrators are also involved in various processes; however, primary oversite for the day-to-day activities falls under the compliance and quality control department. The compliance and quality control department works with other departments within CCI, whether clinical or nonclinical, to provide education and guidance for program changes or new program implementation. This department regularly works with other members of the company, including advance practice providers, physicians, pharmacists, and senior level administrators for the development and approval of clinical and triage pathways.
In preparation for participation in the program, several items were targeted as priorities. Two main areas of focus were implementation of new programming and alterations to current programming to impact process improvement. New programming action items included:
- Identification of OCM eligible patients to gather data and bill MEOS payments
- Implementation of the 13-point IOM care plan form (Box 2) and data collection processes
- Creation of nurse navigator triage pathways to facilitate reduction in emergency room (ER) use and hospital admission rates
- Analysis and interpretation of claims data
Process alterations for current programming included:
- Data collection and analysis for quality measures reporting
- Enhanced depression screening
- Clinical pathway compliance and tracking
Implementation and Outcomes
Identifying OCM Eligible Patients
CCI was initially concerned with identifying eligible patients that would meet the OCM criteria. With Medicare being the primary payer of the model, and encompassing over 50% of the total practice population, the correct identification of patients was a springboard for potential successes moving forward in the program.
Flatiron Health developed an OCM platform called OncoAnalytics8 to assist in the implementation of model requirements, including the identification of eligible patients for model inclusion. Using this reporting platform, CCI is able to validate patients who are actively eligible for OCM, identifying necessary data elements for collection as well as potential for billing the MEOS payments.
Through the most recent patient attribution files, CCI is currently identifying OCM-eligible patients with a less than 10% error rate, which can be attributed to available report capabilities and internal review processes. Identification of patients remains a daunting task; however, technology greatly assisted in streamlining the new process.
Implementing the IOM Care Plan
Due to positive processes in identification of patients, implementation of the 13-point IOM care plan became a more manageable task. However, the process for implementation and buy-in was quite difficult at first and was met with resistance from some clinical team members. The OCM team at CCI provides a weekly list to clinical staff to identify which patients are OCM eligible, as well as what components of the IOM care plan need to be completed at the next office appointment.
Initial completion of OCM care plans in the first 90 days of the model implementation hovered between 25% to 80% completion, depending on the physician team. But, through weekly rounding, shadowing with a champion team, monthly meetings, and an incentive program for completion, all physician teams are now completing the care plan and related components with average completion rates between 94% to 100% each month.
Prior to implementing the 13-point IOM care plan, CCI had advance directive documentation completed on only 2% of patients. With the implementation of the care plan, nearly 95% of patients, as of April 2018, have this information documented in a structured field in the electronic health record (EHR). This signifies a success not only to the completion of this difficult conversation but also the ability of CCI to share this information with other providers to deliver continuity of care. Completion of the care plan and distribution to the patient greatly enhanced communication, and many positive comments from patients have been received over the duration of the model.
Pathways to Improve Nurse Navigation
CCI utilizes nurse navigators in a primary nurse model. In an effort to assist nurses in practicing at the top of their scope, and to reduce ER admissions and hospitalizations, the OCM team at CCI sought feedback regarding nursing triage pathways. Several platforms were introduced as potential solutions for pathway implementation, but ultimately, none were selected due to EHR integration issues. Many platforms required using a separate system prior to integration in the EHR, which resulted in poor feedback from the nurse navigators. Therefore, internal pathways were created by nurses on the OCM team.
Pathways were derived from 2 resources, the book Telephone Triage for Oncology Nurses,9 published by the Oncology Nursing Society (ONS) and the Remote Symptom Practice Guides for Adults on Cancer Treatments,10 which was developed by the Pan-Canadian Oncology Symptom Triage and Remote Support Team. The pathways developed included: diarrhea, nausea and vomiting, fatigue, bleeding, febrile neutropenia, mouth sores/stomatitis, and dyspnea/breathlessness. These pathways were chosen because the items represented global issues demonstrated through OCM case studies and were also issues reflected in CCI’s claims data received through the OCM program. Each triage pathway includes a flowchart to arrive at the final clinical decision based on the patient’s symptoms and includes home care instructions for additional education when needed.
These pathways were piloted for 1 month by 2 senior nurse navigators. Feedback was positive, noting that the pathways were a great resource and would reduce time spent asking for physician or advance practice provider guidance and would assist in additional patient education efforts. After positive feedback, the pathways were approved for use by the Physician Advisory Committee. In June 2017, these pathways were rolled out to the team of nurse navigators and electronic and paper versions of resources were provided. Nurse navigators were asked to document pathway use in their notes when appropriate for reported patient symptoms.
Subsequent review of nurse navigator documentation through December 2017 revealed that the triage pathways were not being documented or utilized consistently. This discovery refocused planning and reimplementation to include: additional review of outside software availability for implementing, utilizing, and tracking triage pathways; capability within OncoEMR to build more intuitive text notes, including grading scales and prompting; and additional revision of triage pathways to better reflect current needs and nurse navigator feedback.
Utilizing CMMI Data and Quarterly Reports
Claims data has been provided to OCM practices in the form of historical data at the start of the model, and updated claims data of the 4 quarters prior has been provided at each quarter thereafter. After receiving the first historical data files from CMMI, it became apparent that external assistance would be necessary to glean useful and meaningful information from the claims files and the quarterly feedback reports. CCI decided to partner with an outside firm and can now benchmark performance against other practices, identify areas for improvement, and determine successes and challenges on a quarterly basis. This data analysis provides direction of several programs that impact patient care.
One area of deficiency included palliative care. In a year of data collection, only 4 of 105 patients at CCI had documentation that they received a palliative care consultation prior to their passing. This cemented the need for a palliative care program, and steps have been taken to begin offering this service to patients.
Another area of deficiency gleaned from the claims data included ER use and preventable hospitalizations. A new program, Call Us First, was implemented in early 2017 to combat these issues. Enhanced access to clinical staff through the Call Us First program is instrumental in re-educating patients about the services the practice offers. Patients are being heavily coached to “call us first” for symptom management rather than immediately reporting to the ER. Finally, data analysis continues to support the need for nursing triage pathways. The nursing triage pathways were chosen and implemented based on ER visits and hospitalizations that could have been prevented had there been a greater focus on symptom management during clinic hours.
Altering Processes of Data Collection and Analysis for Quality Measures Reporting
For several years, CCI participated in PQRS with the assistance of an outside consultant to facilitate data collection and mining. In late 2015 to early 2016, many of these functions became internal responsibilities due to the allocation of staff for government quality reporting needs. This allowed the Compliance and Quality Department to become familiar with government reporting language and algorithms within quality measure specifications. This transition was paramount in preparing for OCM quality measure reporting requirements. The OCM team at CCI was familiar with several of the quality measures set forth by the OCM program and needed only to implement documentation process modifications in the EHR to help adapt to the reporting burden.
Documentation of data points in a structured field is not impossible but has been met with resistance. This required additional education for subsets of clinical teams to explain the necessity and importance of documenting specific data points, additional training in new or updated workflows, and shadowing and/or shared experience of a champion clinical employee to engage struggling team members. Implementation and compliance with documentation takes time, and lost time equates to backfilling missing data elements. The CCI OCM team reviews items such as staging, receptor status, surgery status, treatment status and intent, among other data elements on a monthly to quarterly basis to not only provide feedback to provider teams on compliance, but also promote additional education for improved compliance in the future. Compliance with documentation workflows allows for more seamless use of the Flatiron OCM platform in terms of reporting capabilities and limits the manual location and documentation of data elements. Because of workflow compliance and use of Flatiron products, the OCM team can now work through the staging and clinical data submission lists as well as the quality measures reporting lists to complete final reports for data submission to CMMI in about 2 weeks’ time.
Enhancing Depression Screening
Depression screening for patients on active treatment was initiated at CCI in early 2015 and is included as a portion of the survivorship program. The Patient Health Questionnaire-9 (PHQ-9) is a nationally validated tool utilized at all CCI clinics.11 Depression screening is coupled with an anxiety screening tool and is built into regimens to flag clinicians for completion at the initiation of the regimen, halfway through the regimen, and at the end of the regimen. While these activities were automatically assigned for clinical staff to complete, CCI found inconsistencies in completion across all locations. As a result, a new workflow was adopted to increase depression screening and impact potential outcomes. Patients were divided between clinical staff by payer. Medical assistants on each provider team became responsible for administering depression screening to patients with Medicare as their primary payer. A weekly list is provided for identification and tracking purposes. Nurses in the infusion suite were required to complete the screenings on patients with any other insurance as the primary payer. This split the patient load at about 50/50 for each group of employees. Education was provided via meetings to demonstrate workflow and documentation and included the implementation of flow charts to determine patient eligibility and needs, including when a referral to social services (or another provider) was deemed necessary.
In 2017, 3328 total PHQ-9s were completed by 2304 individual patients. Of these, 269 (or about 11% of patients) demonstrated an additional need through the screening process. This was an increase of 14% of individual patients served in 2017 as compared with 2016, with estimated depression screening completion rates at 80% of active treatment patients across the practice.
Clinical Pathway Compliance and Tracking
Although CCI adopted internal treatment pathways based on National Comprehensive Cancr Network (NCCN) and American Society of Clinical Oncology guidelines, these pathways have historically been difficult to track. Options of additional platforms have been investigated to assist with clear documentation, tracking, and reporting capabilities. Additionally, the embedding of NCCN guidelines into OncoEMR is also an active option for the clinic.
In demonstrations and review of both options, the providers’ workflow disruption is paramount and other means of tracking compliance are continuing to be investigated. At this time, the CCI team will randomly select a subset of patients by disease type for each provider, navigate through the pathway algorithm, and determine compliance rates. This process is time consuming, which limits the frequency in which it can be performed and impacts the quality of feedback that can be delivered to providers. A large focus in the coming months includes determining a more effective method for updating clinical treatment pathways, gauging a provider’s pathway compliance, and delivering feedback to providers.
The next steps and concluding remarks are on the next page
Next Steps
While several areas of OCM program implementation have been successful at CCI, several aspects continue to require additional investigation and data analysis to determine effectiveness and level of impact on the quality of patient care and cost to the Medicare program.
Though CCI continues to experience downward trends in hospitalizations and ER utilization, as well as increased hospice use in the last 30 days of life on recent quarterly feedback reports, additional areas for cost containment are continuing to be explored. Main areas of analysis for improvement include analyzing nursing triage pathways and provider pathway compliance in hopes to minimize unnecessary costs, provide high quality care, and improve the patient experience. Additionally, analysis surrounding drug utilization and patient care are also necessary, as this will be an area in which costs continue to rise for practices providing high quality, innovative therapies to patients.
Conclusion
Thus far in this OCM journey, CCI has successfully identified eligible patients, completed required documentation points, and increased awareness and outcomes for patients related to depression screening, hospitalizations, and ER and hospice use. The practice will continue to optimize processes related to pathway compliance and tracking to improve patient care outcomes. The presentation and discussion of CCI’s process improvement activities, challenges, and successes serve to inform other practices also participating in OCM with the aim of aiding in their practice strategies through shared experience. CCI looks forward to adding to these experiences with the added insight of comprehensive data in the next article.
References
1. Oncology Care Model. innovation.cms.gov. https://innovation.cms.gov/initiatives/oncology-care/. Updated March 6, 2018. Accessed on April 2, 2018.
2. Carevive. The oncology care model (OCM) explained. Carevive.com. https://www.carevive.com/the-oncology-care-model-model-explained/. Published March 31, 2015. Accessed April 19, 2018.
3. The Physicians Advocacy Institute. Oncology care model (OCM) overview. Ncmedsoc.org. https://www.ncmedsoc.org/wp-content/uploads/2017/01/Oncology-Care-Model-Overview-logo.pdf. Published 2017. Accessed April 19, 2018.
4. Quality payment program. What to report. Qpp.cms.gov. https://qpp.cms.gov/mips/what-to-report. Accessed April 19, 2018.
5. Oncology Care Model. cms.gov https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-06-29.html. Updated June 29, 2016. Accessed April 2, 2018.
6. Oncology Care Model (OCM) Request for Applications (RFA). innovation.cms.gov. https://innovation.cms.gov/Files/x/ocmrfa.pdf. Updated June 3, 2015. Accessed April 2, 2018.
7. Oncology Care Model frequently asked questions and application overview webinar. innovation.cms.gov. https://innovation.cms.gov/Files/transcripts/OCM-FAQ-App-trans.pdf. Published April 22, 2015. Accessed April 19, 2018.
8. Flatiron Health. OncoEMR. Flatiron.com. https://flatiron.com/oncology/oncology-ehr/. Accessed April 19, 2018.
9. Hickey M, Newton S, eds. Telephone Triage for Oncology Nurses. 2nd ed. Pittsburgh, PA: Oncology Nursing Society; 2012.
10. Pan-Canadian Oncology Symptom Triage and Remote Support (COSTaRS) Team. Remote Symptom Practice Guides for Adults on Cancer Treatments. Ktcanada.ohri.ca. https://ktcanada.ohri.ca/costars/Research/docs/COSTaRS_Pocket_Guide_March
2016.pdf. Published March 2016. Accessed April 19, 2018.
