At home with the specialist: Oncologists and other specialists launching patient-centered medical homes

Solo practice endocrinologist Carol Greenlee is one of a small number of specialist physicians in the country who operate their practice as a patient-centered medical home, a model pioneered by primary-care doctors. She has expanded the medical home into a medical “neighborhood.”

From her office in Grand Junction, Colo., Greenlee studies patients' medical records and questions their other doctors so she is thoroughly familiar with their health issues before they arrive for visits. She also consults with other doctors electronically on difficult cases, which often makes it unnecessary for patients to come in for visits to her office.

But for now, she receives no additional payments from insurers for these patient-management services, despite having earned patient-centered specialty practice recognition this year from the National Committee for Quality Assurance. “We communicate back with the primary-care doctor after every one of our patients' visits,” Greenlee said. “But some of our patients might not use a primary-care doctor, so we have to look after them a little more.”

Greenlee hopes her NCQA recognition will inspire other small physician groups to transform their practices, and send a message to Medicare and private insurers that they should financially reward doctors for offering this higher level of service to patients.

Despite tensions between primary care and specialist groups over what types of practices should serve as medical homes, a growing number of specialist practices, insurers and health systems are moving toward the patient-centered specialty home model.

The NCQA's patient-centered medical home recognition program has about 8,400 participants, mostly primary-care practices. Its Patient-Centered Specialty Practice recognition program, launched in March 2013, has gotten off to a slow start, however. Tampa, Fla.-based HealthPoint Medical Group was the first to gain recognition in February. Thirty other specialty practices have since followed. The list includes 10 oncology, four endocrinology and two cardiology groups.

The NCQA expects interest among specialist physicians to increase, though the group may have to refine its medical-home criteria to better fit with clinical approaches and patient characteristics of the different specialties. Leah Kaufman, who heads the NCQA's outreach efforts, predicted the program would grow when more insurers introduce payment mechanisms to reward the extra work that goes with being a medical home. “We're starting to see some payer support,” she said. “They are interested in cardiology, endocrinology, oncology and some OB-GYN.”

Some oncologists also have adopted the medical-home model, which is based on the principles of enhanced communication and coordination of care, expanded access through evening and weekend office hours, as well as phone and electronic contact, provider teamwork, proactive assistance to help patients manage their own health, and continuous performance tracking and quality improvement.

At the New Mexico Cancer Center in Albuquerque, CEO Dr. Barbara McAneny calculates that her medical home-style practice model has reduced the hospitalization rate for the 7,200 cancer patients participating in the seven-state oncology medical-home demonstration project she leads from 25 to 18 days per 1,000 patients. Her Community Oncology Medical Home, which she calls Come Home, has established evening and weekend hours so cancer patients can come in and see familiar providers in a comfortable setting.

Patients “are thrilled with the idea of not having to go to the emergency department for eight hours or more and then being seen by someone who's unfamiliar with them,” said McAneny, who is also chair of the American Medical Association board of trustees. “If you know your remaining number of days is limited, the last place you want to spend them is waiting in emergency.”

But the primary-care physician groups that spearheaded the medical-home movement say specialist practices generally cannot function as true medical homes. They argue that one of the core principles is a “whole-person orientation,” and that specialists don't fit with that orientation given their focus on particular organ systems and disease conditions.

“If (specialists) are seeing someone every day, they're probably managing an acute problem, but that doesn't constitute a patient-centered medical home,” said Dr. Reid Blackwelder, president of the American Academy of Family Physicians, which, along with the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association, developed the medical-home joint principles.

In response, Dr. John Sprandio, whose nine-doctor oncology and hematology practice in the Philadelphia area became the first non-primary-care practice recognized by the NCQA as a patient-centered medical home, said oncology practices are fully capable of meeting the medical-home criteria in that they provide acute, chronic, preventive and end-of-life care. He added that cardiologists, nephrologists and rheumatologists also provide chronic-care management to their patients over a long term.

McAneny agreed. “When a person gets diagnosed with cancer, all their other problems go on the back burner and cancer becomes their main focus,” she said.

Dr. David May, a board member of the American College of Cardiology, said that for patients with heart transplants or end-stage renal disease or who require complex pharmacology, specialists are the heart of the care team. “In that environment, it should be the primary-care physicians who are the consultants,” he said.

Some insurers are moving ahead with specialist-based medical homes despite the professional disagreements. Aetna is launching an oncology medical-home network on Jan. 1 as a pilot project, said Dr. Michael Kolodziej, Aetna's national medical director for oncology strategy. It will involve 20 to 25 oncology practices and more than 100 patients in Atlanta, Dayton, Ohio, and Fort Worth, Texas. Aetna will focus on patients with breast, colon and lung cancer because those cancers account for 50% to 60% of patients utilizing chemotherapy. The insurer hopes to improve the patient experience by managing medication toxicity, reducing hospitalizations and trimming costs by 10% to 15%. While the number of patients is small, it's enough to test the concept because of high hospitalization rates for cancer patients, Kolodziej said.

Sprandio praised Aetna's effort overall but disagrees with the insurer's focus on only breast, colon and lung cancers. That may cover most cancer patients, but those types of patients are not the ones who use the most resources because they tend to be younger, have more standardized treatment protocols and experience fewer ED visits, he said.

Pittsburgh-based UPMC Health Plan, owned by the UPMC health system, which already operates 384 primary-care medical home practices serving 255,000 patients, also is launching a specialist-based medical-home model. It will examine which disease states best lend themselves to the model, said Sandy McAnallen, senior vice president of clinical affairs and quality performance for UPMC's insurance services division. UPMC Health Plan's first such effort will be headed by Dr. Miguel Regueiro, a gastroenterologist who is launching a medical home oriented to inflammatory bowel disease for patients with ulcerative colitis and Crohn's disease.

McAnallen said the practice will take a team-based approach and include a primary-care nurse practitioner and a psychiatrist.

Among health systems, the Eastern Maine Medical Center in Bangor has four specialist practices that have earned NCQA recognition as patient-centered specialty practices, including its centers for diabetes and endocrine care, gastroenterology, vascular care and rehabilitation. Its cancer care and women's health centers also have applied for recognition. “It is time-consuming, but it's absolutely worth it,” said Elizabeth Perry, Eastern Maine's lead quality analyst and physician practice administrator.

But insurers' recognition of Eastern Maine's medical home-based quality efforts has been “variable,” said Dr. James Raczek, the system's senior vice president of operations and chief medical officer. Anthem Blue Cross and Blue Shield, in particular, pays above and beyond typical office- visit reimbursement.

McAneny in Albuquerque received a $19.8 million Health Care Innovation demonstration grant from the Center for Medicare and Medicaid Innovation to expand her oncology medical home model to centers in Florida, Georgia, Maine, New Hampshire, Ohio and Texas. Under the three-year project, participating oncology practices will provide 24/7 access, care management, patient education and team-based care. The goal is to produce more than $33.5 million in savings for Medicare and Medicaid beneficiaries with lymphoma or breast, colon, lung, pancreatic, skin or thyroid cancer. McAneny expects to have 8,022 Medicare patients in the program plus 1,530 patients covered by Medicaid or commercial insurance. She has projected a 6.3% savings per patient, or $4,178 a year.

Cardiologists will also join the movement to medical-home practices, the American College of Cardiology's May predicted. The medical home “fits hand in glove” with accountable care organizations, he said. But he expects that cardiologists' participation in NCQA's recognition program will be “abysmal” as long as the group's performance criteria focus on care processes rather than outcomes. His own cardiology practice in suburban Dallas already uses medical home techniques, such as involving patients' family members in their care management.

Researchers are studying the quality and cost benefits of specialist-based medical homes, funded by the Patient-Centered Outcomes Research Institute. The NCQA is spearheading a $2 million study evaluating the performance of oncology medical homes in southeast Pennsylvania. In addition, Denise Hynes, a University of Illinois Chicago professor of public health is leading a $2.1 million study evaluating a medical home for end-stage renal disease patients served by the U-I Hospital and Health Sciences System dialysis center and Fresenius Medical Care.

Also, a new recognition program is competing with the NCQA for specialty-based medical homes. The Washington-based Community Oncology Alliance is working with the American College of Surgeons' Commission on Cancer to develop standards and performance measures for oncology-based medical homes. The effort is being piloted at 10 oncology practices—including the seven participating in McAneny's innovation project. The goal is for the ACS commission to begin accrediting oncology medical homes in 2016.

McAneny said much depends on more insurers paying specialist practices for the extra services medical homes offer patients, preferably through a per-member, per-month fee. For example, at her practice, when patients telephone, a live operator always answers. “Patients who are sick and scared talk to a human immediately,” she said. “That is not something you can bill for in the current fee-for-service system.” Plus, the open scheduling system and keeping the center open late and on weekends mean higher staffing costs.

“Most (insurance) medical directors get it loud and clear,” she said. “But their contracting arms don't always understand that keeping patients out of the hospital is in their best interests.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks