It struck Dr. Barbara McAneny a decade ago that whenever chemotherapy complications sent cancer patients to the hospital they'd come out a little bit worse.
"Each time, it's another step down," the oncologist said. Their immune systems are vulnerable to infections from other patients, and when they go home, they’re "just a little bit weaker, a little more debilitated.”
There’s also a huge financial toll. Hospitalization can cost $30,000 or more, and patients are billed for co-payments and deductibles. Many patients who survive cancer lose their jobs or can no longer work. “People are just devastated by the diagnosis of cancer in more ways than you would think, beyond the medical and physical,” she said.
So McAneny set out to develop a better way for the 3,500 new patients she sees each year at her New Mexico Cancer Center in Albuquerque and three satellites.
She started with weekend “shot clinics,” in which patients could get injections to boost their white cells, later adding weekend office hours and same-day visits, focusing on keeping patients away from hospitals and avoiding emergency departments unless they absolutely needed to be there for life-saving care.
She knows from experience that a hospital — with all its varied infections — is often the worst place any cancer patient with a low white cell count should be.
The longer they wait in an emergency department before being diagnosed, the longer it may take them to receive antibiotics, and the more likely they will deteriorate quickly and end up in the intensive care unit, she said.
McAneny’s three-year program, called Come Home or Community Oncology Medical Home, was funded with a $19.8 million federal demonstration grant until last year. It operated in seven cities from Maine to New Mexico.
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Now, a preliminary analysis of the results has shown that, just as McAneny could see in her own patients, her program saved money and made care safer.
Parts of Come Home have been adopted as a national model for treating Medicare beneficiaries with cancer, and were implemented starting July 1 by 3,200 oncologists who administer chemotherapy. On Nov. 1, the American Society of Clinical Oncology announced a collaboration with Come Home to help other oncology practices lower costs and improve their quality of care.
The 208 people on her staff are trained and ready to respond to patients' chemotherapy complications — like infections, fever, dehydration or diarrhea — nipping most in the bud, even at night and on weekends. The practice stays flexible enough to see about 15 to 20 patients on the same day they call.
"They come here, not to the emergency room where they would sit next to some guy with pneumonia for eight hours," McAneny said. "And delayed care in cancer is bad care."
McAneny said that for a patient with a fever and low white cell count, even a five-hour wait in the emergency room can mean the difference between life and death, or a much longer hospital stay. “We need to get them on antibiotics right away,” she said.
According to a 2010 report from the health care consultant Milliman, for every 1,000 commercially insured patients undergoing chemotherapy, there are 929 visits on average to the emergency room and 378 inpatient admissions. In McAneny’s experience, a patient who goes to the emergency room has up to a two-thirds chance of getting admitted, often needlessly.
After all, hospitals "know nothing about helping people stay out of the hospital. Why would they? Their business is putting people in the hospital," she said.
Emergency room doctors know gunshot wounds and car accidents, but they don't understand what cancer drugs do to a patient, she said. "Our patients come in and they're skinny, and bald and don't look healthy. They take one look at them and say 'My gosh, you need to be in the hospital.'"
But she’s shown that many of these patients don’t. Compared to 10 years ago, when on any weekend 25 to 40 of her cancer patients were hospitalized, the number these days is more like 10 to 15, including patients there for stem cell or bone marrow transplants who could not get that care in her office in any case.
McAneny’s cancer model is not the only one that has tried to reduce hospital stays and cancer treatment costs. Health insurers like United and Aetna have launched some models as well.
But Dr. Mark McClellan, former administrator for the Centers for Medicare & Medicaid Services, said McAneny’s Come Home program’s “unique features” benefit Medicare patients with cancer, whose age and other medical conditions often make their diseases more difficult to manage.
"Come Home has taught us that there is a better way to deliver cancer care with more emphasis on managing the patient’s needs, getting them addressed outside the hospital, and reducing costs and complications," McClellan said.
Ted Okon, executive director of Community Oncology Alliance, which represents cancer doctors, said Come Home informed cancer treatment. “I think the biggest lesson that we learned from the Come Home model is that we can do a much better job of keeping patients out of the hospital,” he said.
Saving $18 million
McAneny tried to pitch cost savings to local health insurers, who she thought would embrace an opportunity to save money and improve patient care. She tried to make the case to Albuquerque’s Presbyterian Health Plans Inc. that for the year 2010, her model could save them $18 million.
Instead of hospital bills that could run in the tens of thousands per patient, McAneny’s model of administering blood work, a CT scan, fluids and antibiotics in her office would bring the bill down to $1,500. And patients would go home and sleep in their own bed that night instead of waiting in an emergency department.
But Presbyterian didn’t buy it.
She said the problem was the health plan and the hospital were part of the same corporation, and if costs were reduced by $18 million, that would be money “stolen” from the hospital. A company official, whom she declined to name, actually used the word “stolen,” she said. She emphasized that the money wasn’t to be diverted to her practice; it was money the health plan didn’t have to spend.
Just after the Affordable Care Act passed in 2010, McAneny — who is active in the American Medical Association and is running to become its eventual president, found herself in a meeting with Dr. Richard Gilfillan, then director of the $10 billion Center for Medicare & Medicaid Innovation. The agency was created by the Affordable Care Act to fund demonstration projects to find ways to lower costs and improve care.
Gilfillan, McAneny recalled, had been complaining that many demonstration projects launched in the last decade weren't living up to their cost-saving expectations.
"I raised my hand and said, 'Of course they're not saving money. They're built around hospitals, which are the most expensive and the most dangerous part of the health care system. What did you expect? They make money by having hospital beds full.'"
CMMI awarded her $19.8 million to help seven oncology practices across the country set up triage centers in their offices, enrolling 26,000 patients starting in 2012. The idea was to see if rapidly responding office-based doctors and nurses, and coordination of cancer services could keep people out of the hospital, reduce costs and improve quality of care.
Newly analyzed data shows Come Home succeeded.
McAneny said the program avoided 10 emergency room visits and three hospitalizations per 1,000 patients per quarter. For those patients who were admitted, Come Home had lower rates of readmissions within 30 days compared to other practice settings in the test cities.
None in San Diego
Earlier this year, the Centers for Medicare & Medicaid Services rolled out a new national model for cancer practices, called the Oncology Care Model or OCM, which incorporated many key elements from Come Home.
The goal of the five-year program is to reduce cancer spending, improve outcomes for these patients and better coordinate care for Medicare beneficiaries. Starting July 1, Medicare pays oncologists $160 per month for each chemotherapy patient starting with the month of their first treatment. Those practices use the money to coordinate care and, if possible, manage complications in their practices instead of the hospital
For reasons that are unclear, no San Diego County oncology practices are among the 195 in the country that signed up for the OCM model. The closest practices enrolled in the OCM are in Fountain Valley and Long Beach.
Numerous San Diego-area oncologists declined to comment or did not respond to inquiries. But one, Dr. Charles Redfern, said this region has a larger share of Medicare beneficiaries in managed care plans, which already have an incentive to reduce unnecessary costs. Statewide, 39 percent of Medicare beneficiaries are enrolled in managed care plans.
Another factor may be that most of the OCM participants around the nation are community oncologists, while a large portion of San Diego oncologists are hospital based.
There also is a sense that practices are performing some services the way the OCM model does, although they may not be as extensive.
For example, Redfern said his Kearny Mesa practice has managed chemotherapy complications in the office for 30 years.
“Patients call 24 hours per day, seven days per week to discuss issues and decide about need for emergency room,” he wrote in an email. “We try to manage symptoms over the phone and see patients in office and avoid the hospital.”
But what if a patient calls at 4:30 p.m. on a Friday, or 9:30 a.m. on a Saturday with symptoms that sound like they could be resolved with rehydration and antibiotics?
"If it is at night or on weekends, the patient will get sent to the ER. We then call the ER and make that step as easy as possible," he replied. "Usually we give orders to the ER staff and the patient is treated and sent back home."
That falls short of what is intended with the OCM, and what the Come Home model accomplished.
A patient’s story
Former Albuquerque banker Sharon Engel, who was recently diagnosed with breast cancer for the second time and again suffered serious chemotherapy complications, said McAneny’s model may have saved her life. At the very least, it gave her a much faster, more pleasant and healthier experience out of the hospital compared to what she endured 14 years ago.
Back then, three days after her first infusion, the drugs' side effects overwhelmed her.
"I felt like I was dying; I just felt like crap" with a high fever and fatigue, she recalled. It was all she could do to drive herself to the closest emergency room, which admitted her for four days.
Engel recovered. But this summer, breast cancer was caught in a mammogram. And again Engel, now 72, developed serious side effects from chemotherapy — this time dehydrating diarrhea serious enough to send her to the hospital. It was late on a Saturday afternoon when she realized how quickly she was getting worse.
This time, however, Engel didn't go to the hospital.
Instead, she called McAneny's New Mexico Cancer Center, where a nurse practitioner logged her symptoms and arranged to see her the next day.
After two hours of medication and a saline drip, she went home feeling much better and got back on schedule with her chemotherapy.
McAneny said she and her team reassure patients that it’s important for them to come to her practice first, and not call 911. "We know what drugs you’re taking, what their side effects are and are not. We can take care of you here. And if you do have to go to the hospital, we’ll arrange for transportation and make sure you don’t have to wait in the ER.”
But McAneny is worried that major health systems across the country are hiring providers to treat cancer patients in hospital-based systems, or buying up physician oncology practices.
That’s apparent in some recent statistics. An April Milliman report shows patients are receiving chemotherapy infusions much more often in hospital based facilities than independent physician office practices. And the care is more expensive.
A report from a Washington, D.C., based health care research company, Avalere Health, showed hospital outpatient departments were paid 21 percent more for an average three-month chemotherapy care than physicians’ office-based practices were paid.
"That’s entirely the wrong track," McAneny said. "It might work in a small number of integrated systems, like Geisinger or the Mayo Clinic, but when there’s no competition, prices go up, not down."
Although data so far seem to support McAneny’s model, she worries that her practice may not see the future.
She sued Presbyterian Healthcare Services, Presbyterian Health plans and Presbyterian Insurance Co. Inc., challenging the fact that the health plan and the hospital were part of the same corporation, which she says violates antitrust laws.
Jeffrey LeVee, an attorney representing Presbyterian, denied McAneny’s complaints. He said one part of McAneny’s claim against Presbyterian’s hospitals has been dismissed. He declined to comment further on the record.
McAneny persists but says if she loses her case against Presbyterian, "I don't know if we'll still be here.”
