A Preemptive Leap to Patient-Centered Care

Kashyap Patel, MD

Kashyap Patel, MD, saw the first signs that fee-for-service was doomed eight years ago. He was serving on South Carolina’s Medicaid board when he received a report about CMS’s plans to test new payment models.

A few years later, when the first of those pilot programs began to show strong improvement in savings and outcomes, Patel and his partners at Carolina Blood and Cancer Care (CBCC), which has an office in suburban Charlotte and another in rural South Carolina, decided to jump ahead and switch from fee-for-service to one of the new patient-centered care models.

Because they realized that success hinged upon getting payers to change payment protocols, they reached out to their payers before they changed anything and asked what they’d need to do to get compensated for the services they would add and how they could share in the overall cost savings.

The answer they got was that they’d have to make a full commitment to one of the new models. “The payers wanted us to get formal accreditation to demonstrate that we were properly executing one of the new patient-centered models in its entirety. That limited us to some degree, because there are still caps on how many practices can be accredited in the pilot programs of some very interesting models, such as the patient-centered oncology home,” said Patel.

After due diligence, CBCC decided to adopt the Patient-Centered Specialty Practice (PCSP) model from the National Committee for Quality Assurance. The model is designed to reduce waste and improve outcomes through superior coordination of care (Figure). “We worked very hard for 18 months, and we lost money during that time, but patients and the practice will both end up benefitting from the move,” Patel said (Table).

To begin the transformation to patient-centered care, physicians at CBCC began by asking patients to explain what they knew of their own diagnoses and treatment. The responses were hazy, so the practice experimented with different consultation templates until it cobbled together something that not only made patients more aware, but also enabled them to make better decisions about treatment.

The next step was to guarantee same-day urgent care appointments for patients who called during business hours and next-day appointments for patients who called at night. The practice looked for ways to tweak its scheduling protocol, but the only way to ensure immediate service without canceling less-urgent appointments was to stay open for an hour longer each day and to put staff on call during weekends.

As the practice expanded its ability to see patients quickly, it also began training its nurses to recognize when patients require rapid treatment. Like many other practices that have moved to patient-centered care, CBCC began using telephone triage flowcharts. The charts list every common patient concern and guide nurses through a series of questions that determine the appropriate response.

The combination of telephone triage and immediate appointments is a cornerstone of the patient-centered care model. It is designed to keep patients out of the emergency department (ED), both by preventing health problems from becoming emergencies and by reassuring patients when emergency care is not necessary. Pilot programs to date suggest that these strategies help reduce ED visits by 15% to 50%.

CBCC’s experience also suggests that the change has significantly reduced the tendency of its patients to visit the ED. However, payers have hesitated to share the savings so far, mostly because the practice’s patient volume is low enough that it’s hard to separate the effects of the care model from mere chance.

“We have about 100 patients undergoing chemotherapy at any given time, which is too small a number to demonstrate statistical significance over the time that has passed since we were accredited,” Patel said. “We’re doing a monitoring program through Medicare’s Oncology Care Model (OCM) that should allow us to estimate cost savings accurately by the middle of next year. Even without that, as soon as we got accreditation, our payers recognized a lot of additional codes, and that made this a profitable model for us. Once we share in cost savings, we will be in a very good position.”

In addition, CBCC will be able to secure increased payment for its Medicare patients, who represent more than half of its patient base, once it is certified in the OCM model. Because the requirements for OCM certification are very similar to those for the PCSP certification that it already has, the practice expects that it will take far less time to earn this second accreditation.

Patients who select a practice certified in these models can expect unusually thorough information about their condition and treatment options. At CBCC, this includes information up front about how to gauge the efficacy of treatment and when to consider switching from curative treatment to palliative care.

“Nearly all cancer patients receive some sort of palliative care to reduce the symptoms of disease or treatment, and I think that most practices have increased the emphasis they put on using palliative methods to keep patients comfortable,” said James Welsh, MD, a CBCC partner who is board-certified in both palliative medicine and hospice care. “We’re certainly not unusual, then, in offering palliative care, although my expertise with it may lead us to undertake more palliative care than other places and to talk more to patients about the decisions they may eventually face before treatment starts at all.”

Whereas a significant amount of research suggests that patients with cancer with little hope of surviving more than a few months enjoy better quality of life when they stop curative treatment and move exclusively to palliative care, Welsh and his partners don’t try to push patients down any given path. “There are so many intangible factors at play—religious beliefs, the need for hope, etc—that a physician cannot tell a patient what the ‘right’ decision is. All you can do is give patients all the information they could possibly want as early as possible and be honest with them about the likely outcomes of various courses of action.”

A patient who comes to CBCC with a late-stage cancer that’s likely to be fatal will not have to wait long for caregivers to discuss issues related to advanced care: writing a living will, assigning a loved one medical and durable power of attorney, getting affairs in order, and considering where to go for hospice care. Having such discussions earlier is actually a part of most patient-centered care models. It is considered to be one component of improved communications, but CBCC officials say they were doing this long before it was incorporated into patient-centered care.

Looking forward, Welsh would like to improve the transition for terminal patients who eventually opt for hospice care. “Hospice eventually becomes the right choice for a significant number of cancer patients, but the current system forces patients who make the transition to stop seeing the oncologists who best understand how to manage their symptoms. Existing Medicare regulations say that hospice patients must receive all their care from the hospice,” Welsh said. “We typically manage to maintain contact with our patients until the end via the telephone or by unreimbursed visits, but those rules are a serious barrier to continuity of care and to quality of care. I think a significant number of patients would benefit by seeking hospice care a bit earlier if they could keep seeing the doctors they had developed relationships with.”