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VBCC - March 2012, Volume 3, No 2 - Best Practices

Interview with Linda Bosserman, MD, Clinical Oncologist and President of Wilshire Oncology Medical Group, La Verne, CA BEST PRACTICES

Over the past several years, Wilshire Oncology has transformed its patient care to patient-centered medical home management, working with the largest payer in California. Value-Based Cancer Care (VBCC) asked Dr Bosserman to describe the new pilot and what has led to this reengineering of cancer care.

VBCC: Can you briefly describe your practice and the recent transformation in care management?
Linda Bosserman, MD:
Our group has been in southern California for 54 years, starting in Los Angeles, then moving east to now serve what is referred to as the Inland Empire—eastern Los Angeles County, San Bernardino County, and Riverside County. Many hospitals and small oncology groups serve different medical groups and medical populations throughout this region. Initially our group came together around clinical research. As managed care came in and dominated the Inland Empire, we began to work in the managed care space. It is a long learning process for doctors, who are often rugged individuals, to effectively interact with colleagues and their different payment systems, particularly trying to articulate what the oncology needs are and what quality oncology care is.

This happened over a time, when it became possible to implement electronic medical records (EMRs). We began using EMRs in 2000. In 2003, we put it in an oncology-specific system, then in 2005, we converted to a customizable oncology-specific EMR. We initiated monthly group meetings to ask, "What are the standards of care we need programmed? What information would we enter? How would we enter it? Who would enter it? What is important? What data could we study and understand about our care delivery?" We implemented our findings with the EMR and reengineered our practice as a result. We reconstructed staff positions to contribute to quality care, patient experience, and collecting a dataset that could be used to understand what we were doing and how we were doing it. We asked whether the right person was getting the right cancer care for the right disease, and what the associated outcomes and costs were. Our group developed a vision of what these records could look like. We began to think of medical care as something you could define, prove, and understand the outcomes and cost of. Our goal is also to ensure that patients have satisfaction with personalized care: by being educated honestly about their choices and outcomes, relieving side effects, and lowering their cost of care.

Many EMRs do not have the detailed reporting capabilities that we all need to keep improving and looking at where we are spending money. With the new pilot and data from other large national networks, we will eventually be able to know what adjuvant therapies work for different tumors and for different age-groups of people with different comorbidities; things that clinical trials are not large enough or powerful enough to tell us. We can keep improving our care in America through data and analytics and outcomes.

VBCC: What is the approximate size of your center or clinic?
Dr Bosserman: We are a part of US Oncology McKesson Specialty Health now. The network sees approximately 800,000 new patients annually, and we see 4500 new patients annually. We have many small centers in southern California. Over these years, we developed 6 private cancer center offices, 2 of which have radiation therapy, 1 has a PET CT, and all the offices have clinical research trials. Approximately 5 years ago, we took over all of the care for patients with cancer—inpatient and outpatient—for San Bernardino County, which is the largest geographic county in America, as well as one of the poorest. Then, approximately 3 years ago, we were asked to take over cancer care for Riverside County patients, because we had a proven program of data reporting and team work that we could integrate with their nursing, pharmacy, and medical staff to meet their growing patient care needs. We have standardized all treatment protocols to be cost-effective, reengineered all of our staff, and developed an extensive training and partnering program with mid-level providers at private sites which we extended to both county programs.

We have 10 doctors and 8 mid-level clinicians (nurse practitioners and physician assistants) and are in the process of hiring 2 more physicians and 2 more mid-level providers. We run the county programs with 2 midlevel providers per doctor, plus a clerk. We standardized all of the charts; we work with the county pharmacists, nurses, and healthcare staff. We have brought private-practice efficiencies and data reporting to county medicine. In our first 2 years, we were up 450% in patient volume in the inpatient setting and 250% in the outpatient setting at the Riverside site alone. Both counties are experiencing significant growth because of the region's high 26% uninsured rate and the ongoing 12% to 14% unemployment rates.

VBCC: Who pays for all this?
Dr Bosserman:
In California, indigent care is most often paid for by the counties. It is provided most often by academic centers. We used all of our learning on the private side and our managed care experience to be able to serve the indigent patients cost-effectively. We help them with free care programs and all of the generic drug regimens and standardization we use in our private sites.

VBCC: Was your EMR a big help in terms of efficiency?
Dr Bosserman:
Actually we have learned that EMRs do not save time or make doctors more efficient. Rather, they allow us to meet multiple needs at once. When we look at EMRs, they are very structured ways to collect data and generate reports. They help us take better care of the patient by our programming to prompt correct decision-making at the time of care and recording disease and patient details, warranted variations, symptoms and their management, triage and interval care, as well as end-of-life care. There is also a patient component to that, which for now we have patients fill out standardized reports and plan to move to electronic patient entry.

VBCC: What is involved in standardized reports by patients?
Dr Bosserman:
We try to find out everything about new patients before they even come into the clinic. Then, patients on therapy are given forms to fill out before they return or on the day of the visit. The on-therapy form is a standard report that tells us everything that happened to him/her since the last treatment. Was the patient in the hospital, the emergency department, urgent care? What was it for? What are the patient's current medications? Are there any new medications? What medications were stopped or started? What side effects did the patient experience? What does the patient want addressed or treated? Usually there are 3- to 4-week intervals between therapy cycles. Our ontherapy reports ask patients about a standardized list of toxicities and their impact. This is a standardized way of making sure that if patients take the time to tell us what is happening and what has happened, we will then spend the office visit focusing on improving their health rather than collecting data.

All of this reengineering forced us to ask, what is it we do? What is it that doctors do? A physician's ultimate training is to analyze data and make decisions based on evidence to achieve the best outcomes and then communicate to the patient. Many people can help in that communication and reinforce it, and other clinicians can actually oversee the treatment plan, symptom management, and follow-up care. We train our mid-level providers one on one with us to work as clinicians at the fellow level of medical training. We have advanced oncology nurses who are highly skilled in symptom management, chemotherapy infusion, and oral chemotherapy management. Our medical assistants are brilliant at collecting and entering data and tracking down things, so when we see the patient, we are ready to help improve their health. We really try and make it as seamless as possible for the patient to get care. Active patient engagement is a key component in our care model. The reengineering process makes us think what is it we need to do for patients? What is it we have to do for our payers?

VBCC: Can you elaborate on your work with payers?
Dr Bosserman:
When we stepped back and looked at how we were being paid for care, traditionally medical oncologists grew their practices, and all the extensive support services patients need, based on the margin of the drugs. From the 1980s through the 2000s, drugs became more expensive; there were larger margins, groups grew beautiful offices, we brought in a psychologist, and we developed extensive emotional, psychosocial, financial, and medical support. As the costs became greater and greater, Medicare, and then the private payers, cut the drug margin without raising the fees for the cognitive and support services that we provide to patients. It is the cognitive and support services that help patients get through, and manage their symptoms, and then at the end of life, help them understand when a treatment may not benefit them. When we put all of that together, we had managed care contracts where we learned to comprehensively manage costs in and outside of the office as well as our experiences with our team work in our county contracts.

Approximately 4 or 5 years ago, we said, "We need to take this comprehensive care approach to the private payers, because our patients are being priced out of private insurance. Patient copays are going up, and it is becoming very unaffordable for our patients." In response to growing cancer costs, private payers had implanted many work-arounds via third parties: specialty pharmacy delivery and oversight of drugs, care managers calling clinicians and patients from afar and trying to direct care they were uninvolved in at the community or practice level, and growing authorization programs with continuously expanding dataset requirements for every aspect of our cancer care. These health plan programs added costs and inefficiencies to our integrated team approach as well as frustrating delays for patients at a time they are already overwhelmed by their cancer diagnosis and intensive therapies. These programs were not working for the health plans nor for the clinicians and became a driver for physicians joining larger hospital systems to have more favorable relationships with payers and more administrators to deal with the crushing administrative burdens. We felt that community oncology was the best option for long-term price controls to manage patient copay and payer costs, but a new payment model was needed.

We contacted the largest payer in our practice, which is Anthem Blue Cross WellPoint of California, and brought them to a meeting in our office. They came to our practice, and they thought our ideas were very interesting, but health plans have huge responsibilities to actuarially validate things. The first thing that most doctors do not understand is that health plans are organized into silos. There are medical directors whose responsibility is to ensure that medical policies are followed consistently and appropriately, and that medical policies are up to date. Then there is the contracting team that negotiates the contract. Their incentives are about keeping the contract rates under control with whatever the guidelines are. Then we have the pharmacy team trying to manage pharmacy. In my observation, no one is connected. Approximately 10 years ago, when the health plans began to see costs soar, we all realized that almost 80% of the costs are associated with approximately 10% to 20% of the patients, particularly those with the 5 top chronic illnesses—cancer, heart disease, diabetes, obesity, and hypertension—and in the younger populations, asthma and respiratory diseases.

We then saw the rise of disease management companies. Some nurses would call patients, or they would send programs out. They had many people coming to the health plans with their solutions, which were not about improving their health but about saving money. One of the things we emphasized when we brought the health plan to our office was that we actually manage these patients. We have been doing it in managed care. We work closely with our hospitalists, our primary care doctors, and our surgeons, and we have many examples of how much money we were able to save. Our nurses know when our patients cannot open their pill bottles or if they need things written down. We will then put the pills in a pill dispenser for them, or we call their kids and say, "Mom needs some help here." We really know our patients, and you cannot get that from case management from afar.

VBCC: What is your oncology medical home pilot?
Dr Bosserman:
We launched our pilot in August 2011; it was to be a 1-year pilot, but we are already extending it. We are showing very substantial savings. There are 6 points that evolved and developed into our medical home:

  1. Patient-focused approach. The health plan does not have a description of its full population. Who is it that the oncologists are seeing? What is their age, performance status, comorbidities, actual diagnosis, and disease stage? More decisions on treatment are based on what I call "tumor features." In breast cancer, it is whether the patient is hormone-sensitive, whether she is HER2-positive. In lung cancer, it depends whether the patient has squamous-cell carcinoma or adenocarcinoma. In the explosion that is personalized medicine, the features of the tumor will determine which targeted therapies, and in what combination and order, will give the patient the best outcome. We convinced our payer that we had those kinds of data at the practice, and health plans are beginning to ask clinicians to enter this information online to get treatment authorizations. Health plans need it to understand their population, but we have that data and can report it along with the therapies and outcomes.
  2. Guideline-based therapy and supportive care. All people receiving therapy can receive the most costeffective therapy. We know that many drug regimens have the same outcome, and a study from US Oncology showed that you can save 35% of the costs, with the same outcome in lung cancer. We know that this is true for a lot of different cancers. These drugs tend to be the generic, the inexpensive or lessexpensive regimens. If these drugs have the same outcome, we wanted to make sure doctors were paid to give the right treatment, and not the one that has the largest margin to pay the rent and pay the staff. We showed these models to the health plan. All patients will get cost-effective therapy following evidence-based guidelines, for the treatment and supportive care. Supportive care is getting to be just as expensive. Nausea therapies, therapies for bone metastasis, and red or white cells, all have to be used appropriately.
  3. Interval care management. We see a lot of the small doctor groups that do not have many support staff or nursing because of cutbacks. If the patient gets a treatment, and gets incredibly sick, he/she comes into the hospital for 10 days. The doctor then bills for 10 days of hospital care. But this pattern is truly not good for anyone. For instance, a patient with head and neck cancer who receives combined chemotherapy/radiation needs an early feeding tube, education, home care from day 1, extra care for hydration and nutrition, and management of their electrolytes. This type of care avoids all avoidable hospitalizations and emergency department visits. The impact of that is the patient gets much better care. The patient is kept healthier and feeling better. This centers everything we are doing on helping the patient minimize suffering and stay as healthy as possible during therapy, and it takes an experienced and coordinated oncology staff to do this. Interval care management is the nursing, the physician, the staff management, phone calls, and coordinated care. If someone is not well on Tuesday, we bring them in for a visit. We do not wait until Friday when the patient is so dehydrated that he has to be admitted. If the patient is getting anemic or needs a transfusion, we can manage it right away in the outpatient setting. We stay late in the office. If someone calls with a problem, we ask them to come to the office. We are staffed, and we are spending the time in our office managing and saving everyone the cost. Also, we know the patients. These are our patients, and we take responsibility to keep them as healthy as possible, relieve suffering, and improve their outcomes.
  4. End-of-life care. We have always had the sense that no one wants to give chemotherapy to dying patients. Even before we have reached the end of our options, and another treatment is only going to bring suffering, it is time to have tough conversations about the limits of medicine. There is a time and a place where we can keep people feeling much better and improve the end of their life by being honest with them and offering palliative and hospice care. When you talk to patients, this is what they want. But there has never been the funding to spend multiple visits with these patients and their families, to have tough conversations about when the disease is not responding to therapy and share the information that the patient will do much better on palliative care only and hospice. With end-of-life support, we now get the same funding for care management as we would if they were getting active treatment. It means that the care and the time are valued by the health plan. It gives us time to talk about advanced-care directives before a medical crisis occurs. Patients can have their wishes respected and communicate with their families. They can initiate hospice with our coordination so they can be with their family and have dignity at the end of life.
  5. Transparent data reporting. We now meet every 3 months with the health plan team to discuss all the data and the treatments as well as benchmarks. This has been illuminating. We have so little hospitalization and emergency department visits that it was eye-opening. We have been able to talk to the health plan about how we might even optimize that further. Depending on when patients go for transfusions, for example, if the hospital is full, they may have to wait, and they may end up staying overnight or have a full hospitalization for an outpatient procedure. We are able to transfuse in our office, so it gives us a way to look at how they could cover the blood expenses. Intravenous immunoglobulin (IVIG) has not had a stable price in the market. We never know if the codes will cover the costs of IVIG. Most doctors admit for IVIG, usually as an outpatient, but occasionally if the hospital is busy, the person can end up with an inpatient stay. The health plan can stabilize the price of this so we can move it back to the office. We can also track other cancerrelated care: we have tracked ommaya reservoir, thoracentesis, surgical procedures, and radiation. We can give a complete picture of care, unlike health plans claims data that may take 3 to 9 months. Then it depends on the accuracy of the codes people used for the hospital care. Our process is a very transparent way of saying, "Here is the population you are asking us to manage. Here is what they have. Here is what we did. Here is how we did it. Here are the complications. Here is how they were managed. Here are our costs. Let's benchmark these and continuously work to provide cost-effective, high-quality care to your patients." As a team, we are focused on keeping patients healthier and lowering their costs by minimizing things that are avoidable.
  6. Quality measure validation. Although these ideas seemed great to the health plan, they wanted to be sure that the quality we were providing was reportable against nationally validated quality measures. We are participating in meaningful use and PQRI (Physician Quality Reporting Initiative), as well as being active American Society of Clinical Oncology (ASCO) members. As part of our pilot, we are providing the health plan reports of our results against relevant, nationally validated quality measures.

VBCC: Do you follow your own pathway, or the National Comprehensive Cancer Network (NCCN) or the ASCO guidelines?
Dr Bosserman: Everything we do is consistent within NCCN and ASCO, but we delve deeper to make sure it is also the cost-effective regimen. Our pathways include US Oncology's Level 1 Pathways and are consistent with the health plan's medical policies. But within those ranges, there are vast differences in cost. In fact, we were just reviewing treatments for multiple myeloma. They go from a $25,000 regimen to a $120,000 regimen with the same outcomes. Often doctors never knew all the different costs that went together, especially as oral cancer drugs have become more prevalent in regimens. They can be $6000 to $10,000 per month for an oral drug. Before, the doctor drove the choice; now, we like to reflect value. If 2 or 3 treatments have the same outcome and similar toxicities, we give the one that is the least costly so the patient has the lowest copay, unless there is a reason for a warranted variation.

But the lowest-cost regimens do not have enough margins in them to support the work of the practice. So, the second point at the medical home was to develop a payment plan that supported our delivery of the most costeffective, evidence-based therapy and supportive care regimens. When we look at the major savings in patient care going forward, we need to figure out how to avoid what is avoidable, especially avoidable emergency department and hospital care by taking better care of people. Now with our pilot, we have a system that supports that. We developed a payment system for care planning, so that the care plan, coordination with the surgeon, radiation, and evaluation for clinical trials, rehabilitation, or physical therapy—all that planning that is so important—is paid for, as well as the ongoing active care management for people receiving therapy and end-of-life care.

VBCC: Did you develop the payment method together with the payer?
Dr Bosserman: We did an analysis of what the work components were. Then we showed Anthem Blue Cross WellPoint of California how much savings we thought there would be, by using more cost-effective regimens and preventing avoidable emergency department and hospital care. We agreed on a pilot study fee structure that, once we get all the data, we believe will have a much greater savings. This started 4 or 5 years ago. It was not a priority for the payers then, but they came and they listened. They then engaged their actuaries, who have to analyze the numbers and make sure that this is correct. They would poll our patients, look at regimens, and then compare us to other groups. All of this took months of validation, because health plans have very complex computer systems. We could provide data pretty quickly from our EMR and billing records.

The medical directors have worked diligently with us. They have a lot of responsibilities, and we would have meetings every few months. The pilot took on various priorities at different times. Approximately 2 years ago, the medical director and the actuary came to our office and saw our nurses, and our mid-level providers and talked to patients. That was an important step. When you talk to a medical director who is not trained in oncology, details are overwhelming. Once we agreed on everything and the initial finances, what we are going to track and how we were going to do this, it took a while to get all the legal issues in order. Because health plans have many requirements both to the state and to their parent organizations, it took another year to get all the processes in place to launch the pilot this past August.

VBCC: Is this a model that other practices could follow?
Dr Bosserman:
It is completely scalable, teachable, and implementable. But one thing that all of us have to recognize is that the most important healthcare reform we need is to put the patient at the center of care, not the doctor. Now we are moving to models which can be just as financially rewarding to physicians, but it is going to be as leaders in groups and teams where everything is about the patient. That can be very scary for doctors who are rugged individualists who were trained to make their independent analysis, stand on their own, and defend their decisions. It is a huge challenge, but we are encouraged by younger doctors who are facile with data entry and EMR use as well as trained in more cooperative team care approaches.

Our payer found out that our approach can work. Everybody has talked about accountable care organizations and the primary care model. Primary care can manage chronic diseases such as hypertension and diabetes, but cancer has to be managed by the oncologist. We have to manage with our primary care partners and in the medical home neighborhood, but our work can serve as a model for the kind of reengineering needed at the practice with standardization, staff ing, electronics, data, and analytics.

VBCC: How do you manage your data analysis?
Dr Bosserman:
Now that we are working with McKesson Specialty Health, we have their national actuaries and analytic team crunching all the data for us. They have taken our pilot work to a whole other level with their ability to bring in all the national benchmarking data and additional practice support for all the analytic reporting. For other health plans that want to do this, we have the tools, administrative, and analytic expertise to put these programs in place in partnership with practices.

VBCC: What do you see as your main challenges and rewards?
Dr Bosserman:
The real challenge I see is to stabilize the profession and the reimbursement for the profession. So doctors know, "My job is to go and practice medicine, and I will be rewarded appropriately." You have all these companies and people taking money, changing rules and contracts, and there has been no stability. In my career, it has been a constant change. Every day that I am not seeing a patient is a tragedy. I have become a business and a health plan expert. I evolved my career this way to answer the question, "What is inhibiting me from taking better care of my patients?" If we can share that—have doctors and nurses taking care of people and sharing their years of expertise, but knowing the system is working to let them do that—then everyone wins. The challenge is trust. Doctors are sure that if they are transparent about what they are doing they will not get paid. So our pilot work has just taken a position of validating information and being transparent, because the health plans will tell you over and over that they want the doctors to stay in business and they want their patients to get appropriate cancer care.

Our biggest challenge right now is that doctor groups have been too small, and it has taken too much time for each group to negotiate with their many payers. Doctors do not want third parties in the middle taking money when they are doing the work. This is an opportunity to have a plan in place where doctor groups can stay in private practice and avoid working for hospitals, where patients are charged 3 to 5 times more. It is also a way to stay cost-effective for patients and healthcare premiums. If we are going to have people in private practice, it has to go a lot smoother; it has to be more efficient and standardized, so doctors can go back to practicing medicine. So again, in oncology, our group is unique to have 10 doctors and an extensive staff who actually have fun working together. Our doctors have all developed expertise in different tumors. We listen to each other and work together. Our mid-level providers, our nurses, and our staff are our partners. I am proud of what every member of our team contributes. They all know what it is we are doing and why. We show data at our monthly meetings, and we get ideas and constant improvements from the health plan, as well as from our staff and patients. We are fully engaged in healthcare reform though our medical home pilot.

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