Cardinale B. Smith, MD, PhD
IN ORDER TO rein in the untenable rise in costs while delivering high-value cancer care, the Centers for Medicare & Medicaid Innovation developed a new payment system—the Oncology Care Model. At the 2018 ASCO Quality Care Symposium, Cardinale B. Smith, MD, PhD, shed light on the system’s challenges and rewards when her large health-delivery system transitioned to an Oncology Care Model care delivery and payment system.1
Dr. Smith, Associate Professor and Director of Quality for Cancer Services at the Mount Sinai Health System in New York, began her presentation by describing the footprint of her system. “We’re the biggest health system in New York City, with about 300 locations that span all 5 boroughs and into Long Island and New Jersey,” said Dr. Smith. “Mount Sinai is the mother ship, so to speak, where we have the largest number of dedicated medical oncology beds, infusion chairs, and linear accelerators.”
DR. SMITH emphasized that Mount Sinai did not transition to an Oncology Care Model when the oncology model went live; it was ahead of the curve. “The impetus for the change was when our network grew into a large health system. We’ve been focusing on maximizing value since 2014, which led to our National Cancer Institute Comprehensive Cancer Center designation in 2015,” said Dr. Smith.
“We divided our strategy into four big domains that include process improvement, clinical quality, information technology and reporting, and care coordination.”— Cardinale B. Smith, MD
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The Oncology Care Model payment system is based on performance periods, which are 6-month episodes of care triggered by a patient starting either chemotherapy or hormonal therapy. “In year 1, we had approximately 1,800 episodes triggered, and we anticipate by the end of 5 years, we’ll have approximately 8,500 episodes under our belt, which will change accordingly as our volume increases, said Dr. Smith.
The value-based Oncology Care Model is aimed at creating healthier outcomes and improving care collaboration while reducing health-care costs. Mount Sinai’s vision incorporates a multifactorial approach of new technology and research coupled with multiple teams on the clinical/administrative side, whose collective goal is to minimize variation and maximize quality.
Dr. Smith noted several Oncology Care Model practice design activities such as providing 24/7 access to an appropriate clinician with real-time access to patient medical records, using certified electronic health records data for continuous quality improvement, and providing core functions of patient navigation.
At the outset, however, the Oncology Care Model team faced what seemed to be an insurmountable task. “The idea of taking this on was overwhelming. There were never enough resources or people to get the work done. Moreover, we had a lack of quality data to harvest from our [electronic health record] system, so naturally it’s hard to effect positive change if we can’t measure where we are,” said Dr. Smith.
TO ASSESS their performance level, Dr. Smith and her team pooled certain clinical data with other institutions that are functioning Oncology Care Models and also members of the Association of American Medical Colleges. Dr. Smith displayed a bar graph with 6-month episode findings, which showed that Mount Sinai had lower rates of emergency department admissions and re-admissions than the other institutions, but the data on hospice enrollment were unsatisfactory.
“That really hurt, because I’m a palliative care physician, and [in that field] we clearly know that early hospice enrollment can lower costs and improve quality of life. The results showed us an area that needed our attention,” said Dr. Smith.
So, how did they address their shortcomings? “We divided our strategy into four big domains that include process improvement, clinical quality, information technology (IT) and reporting, and care coordination, which is the domain we devoted most of our personnel and time to,” said Dr. Smith. “Care coordination, both inpatient and outpatient, ensures a smooth transition of care. We employ patient navigators who guide new patients through the continuum of their treatment experience. And we revamped the way we use our social workers—we’re really lucky to have a good number of phenomenal [full-time equivalent] social workers.”
Integrating the Oncology Care Model
THE OVERRIDING challenge was integrating the Oncology Care Model into the existing model of care. They were fortunate to have a chemotherapy council and IT steering committee—which meets monthly with the head of their electronic health record system—in place. To build meaningful relationships, Dr. Smith and her team began monthly Oncology Care Model meetings with key personnel at different sites with their own databases.
Crucial to their plan forward was the chemotherapy council. “We minimized variations in care by putting evidence-based chemotherapy sets into our Beacon Plan [the chemotherapy module of the emergency medical record software used at Mount Sinai]. When guidelines change, we change accordingly. All of our plans and protocols get reviewed by the council, and we then create a scoring rubric to decide what evidence-based metric gets uploaded to our [electronic health record] system,” noted Dr. Smith.
Mount Sinai’s Oncology Care Model data are aggregated and charted in quality measure tables. They are uploaded into a well-organized quality measures dashboard, which records measures such as pain scores and advance care planning processes. “The dashboard lets you clearly see all the measures, and it drills down by site across our health system, including all participants in the Oncology Care Model,” said Dr. Smith.
The transition to the Oncology Care Model has seen early progress in the expansion of social work, care coordination, and improved compliance with treatment summary and disease staging Commission on Cancer requirements. “In terms of quality specifically, we earned the highest score for emergency department visits and hospital admissions—10 out of 10—so we’re doing well. I think a lot of that success comes from the standardized clinical documentation we’ve built to report key quality measures and our dashboard,” said Dr. Smith. ■
DISCLOSURE: Dr. Smith has received honoraria from and is a consultant/advisor to Teva.
1. Smith CB: Personnel roles and responsibilities within OCM. 2018 ASCO Quality Care Symposium. Presented September 29, 2018.