Unnecessary emergency department visits and hospitalizations are not only common for patients with cancer, but also costly for the United States health care system. In an attempt to help decrease these visits and costs, researchers from the University of Pennsylvania led by Nathan R Handley, MD, Perelman School of Medicine, conducted a that identified the five best practices to reduce “unplanned acute care.” To improve health care quality in oncology, Dr Handley and colleagues suggest that cancer centers should aim to identify patients at high risk of unplanned acute care, enhance access and care coordination among health professionals, standardize clinical pathways for symptom management, develop urgent cancer care strategies, and utilize early palliative care.
Journal of Clinical Pathways spoke with Dr Handley about the extent to which unplanned acute hospital care is a concern for the health care system and ways in which care coordination and clinical pathways can help decrease unnecessary spending.
How large of a concern is unplanned acute hospital oncology care for the US health care system?
Dr Handley: There is a variety of data that shows how large this concern actually is. In 2011, there was a study published in the that examined current and projected costs of care at that time. In 2010, the total cost of cancer care in the United States was around $125 billion. Researchers projected that number would reach about $160 billion by 2020 based on population growth alone. But if the cost of care also increased, using a conservative estimate of about 2% per year, then the projected total cost of cancer care would reach about $174 billion by 2020. That figure is not even adjusted for inflation; the 2020 projection is based on 2010 dollars. Over that 10-year period of time researchers were projecting a 40% increase in the cost of cancer care. To this day, that is the number that the National Cancer Institute uses.
Now the question begging to be asked is what percentage of unplanned acute hospital care makes up that $174 billion? There is another interesting study published in in 2014 that looked at cost of care associated with Medicare patients with advanced cancer. Researchers found that acute hospital care was the largest component of spending and the biggest driver of regional spending variation. Acute care utilization was about half of total spending for those cancer patients and about two-thirds of variation between different hospitals that they examined. We often talk about cancer care as having a lot of different cost-contributing components. But in this study, acute care utilization was by far the biggest driver, which can equate to billions and billions of dollars.
This study also shed light on a few other cost-contributing components of cancer care, such as chemotherapy and hospice. Chemotherapy was found to be responsible for about 16% of spending and only about 10% of variation, while hospice care was only about 5% of spending.
A lot of conclusions can be drawn from this data. First, it can be said that acute hospital care is a costly component of cancer care. If we can make efforts to cut down on acute care utilization, we can save a lot of costs as a system.
Second, there is a significant amount of variation across health systems in terms of utilization. The study showed that 67% of variation could be attributed to differences in acute care utilization. It is important to note that we are not talking about a few percentage points; this is a big deal.
The next question that inevitably arises is how much of variation can we impact and how many of these admissions are actually preventable? Those are difficult numbers to accurately determine, but a number of studies have made estimates. One study in the estimated the number was at least 50%; another study in the put the number at 19%.
Part of why it is difficult to determine these numbers is that historically, we have not defined what a preventable admission for a patient with cancer actually entails. However, some legislative changes that are on the docket may soon change that. As part of the hospital outpatient prospective payment changes for 2017, CMS proposed a measure called OP-35, which defines a preventable hospital admission for a patient receiving chemotherapy as one being related to one of 10 conditions (including anemia, nausea, dehydration, neutropenia, and diarrhea). If a patient has a hospital admission within 30 days of receiving chemotherapy, the hospital’s reimbursement for that admission would be negatively impacted.
In short, unplanned and preventable hospital care is a large cost driver.
How can utilizing enhanced care coordination in the acute hospital setting help reduce these unwanted costs? What steps need to be taken to ensure optimal coordination and care for these patients?
Dr Handley: A study published on this topic in the consisted of a pre- and post-analysis of a quality improvement intervention to improve the transition from the inpatient to the outpatient setting. The intervention included baseline provider education about what the intervention entailed, a nursing phone call to the discharged patient within 48 hours of discharge, and a follow-up appointment within 5 business days of discharge. During the phone call, there were a couple of topics discussed, including symptom management, medications, and a reminder about the follow-up appointment. This intervention proved to decrease readmission rates by about 5%. It was not a particularly costly intervention and it demonstrated that there is a clear opportunity for care coordination.
There are some unpublished data out there that are also pretty interesting. The Ohio State University Wexner Medical Center has had a dedicated oncology emergency department since 2015 that has 15 rooms adjacent to their main emergency department dedicated to patients with cancer. An interesting component of their care plan is staffed patient care resource managers, or PCRMs. These individuals are staffed throughout the continuum of care – in the emergency department, inpatient unit, and outpatient units. Every patient that goes into the emergency department comes into contact with one of these PCRMs. They also have this robust mechanism in place for handoffs between the primary team, the inpatient treatment team, and the emergency department team as well. Members of the team have informed me that their readmission rates for patients who come into the emergency department are extremely low, which they attribute in part to their robust care coordination.
The point here is that someone has to take ownership of coordinating care. It can be a large and complicated job. There are a lot of moving parts and it is not reasonable to expect physicians to do this on their own. The best aspect of the patient navigator role is that it provides a definition of what care coordination entails and clarifies the expectations of what that involves – a pathway essentially to what coordination should be.
Perhaps the most well-described and documented patient navigation program is at the University of Alabama at Birmingham (UAB). There was the piece in 2017 and a piece in in 2016 that described the Patient Care Connect program at UAB, which was designed to transform health care through lay navigators. Using lay navigators provided a nice way to interact with patients, divorced from the complexity of medical jargon. These navigators understood how to navigate the system and maintained contact with the patients through face-to-face encounters, as well as by phone and email. They provided a reliable layer of support, protection and guidance that led to significantly reduced acute care utilization.
Click to the next page to read about clinical pathways in acute care
What role can clinical pathways serve in reducing unplanned acute care? Why are pathways considered such an integral part of the process?
Dr Handley: This is where the importance of variation should be considered. If we think back on the data from the study, two-thirds of the variation in spending was attributable to variation in acute care utilization. Different practices are managing their patients differently – and some seem to be doing it better than others. Why is that? There is a major opportunity to determine best practice here.
I believe that clinical pathways are a mechanism to both define best practices and to disseminate what those best practices can be. There are many examples of clinical pathways being implemented and utilized today. One particularly interesting clinical pathway is from a small practice outside of Philadelphia, Pennsylvania: Consultants in Medical Oncology and Hematology. This practice has been utilizing clinical pathways for symptom management and other things since the early 2000s. They also have been measuring their emergency department utilization concurrently with implementation of their pathways. Over a 4-year period, they developed protocols for managing a variety of symptoms (ie, nausea, vomiting, gastritis, and diarrhea). Everyone who was responsible for triage care used these pathways, so when patients presented with these symptoms there was a defined way to treat them. By following those protocols, they decreased the percentage of patients directed to the emergency department by almost 60%. In short, they created a standard best practice that they disseminated throughout the practice, resulting in decreased variation and improved quality of care.
Pathways provide a mechanism by which the process of care can be streamlined if they are crafted thoroughly and implemented correctly. The key is that they are grounded in data and that they have measurable outcomes. For example, if a practice is thinking about implementing early palliative care, it is helpful to know that has the potential to reduce both emergency room visits and hospitalizations by over 25%. A practice can then measure their utilization after implementing an early palliative care intervention to see if they’re achieving the improvements they anticipated.
How can big data, care coordination, and clinical pathways collectively change the way cancer care is perceived and delivered in the future?
Dr Handley: This question can be answered pretty concisely; effective, thoughtful analysis of big data can help us target care coordination via clinical pathways informed by best practices. Ultimately, we can become much more efficient at delivering the right care to the right patient in the right place and at the right time. Big data, care coordination, and clinical pathways can help us streamline care in a way that we have not been able to do historically.
Are there any other important points you would like to make?
Dr Handley: You mentioned at the beginning of the conversation that pathways are a means of providing value-based care. Providing high-value care can be defined in a number of ways, but I will define it as care which is high-quality and at a reasonable cost. Value-based care is going to be a critical component of all health care, especially cancer care, moving forward. There are a number of reimbursement models for value-based care, from shared savings programs to episodic bundles, to partial capitation or full capitation. The point is that we are rapidly moving away from a fee-for-service system to a value-based care system. As we move, we will be more incentivized to become less focused on a single point in time in the patient’s journey. Only then we will become better at looking at the whole picture of the patient’s care.
From a reimbursement standpoint, OP-35 is just one of many mechanisms in place to affect reimbursement based on what is conceived of as value-based care. MACRA’s quality payment program at its simplest level, the merit-based incentive payment system (MIPS), is going to be affecting reimbursement starting in 2019. Ultimately, low-performing groups could see their reimbursement from Medicare cut by 9%. That kind of change is really dramatic, and so focusing on quality and variation in care will be critical to the financial viability of practices moving forward.
We may find a number of things as we continue to explore this world of value-based care and best practices. We may find that alternative sites of care could become more common. I referenced the hospital-specific or cancer-specific emergency department at the Ohio State University Wexner Medical Center, but there are a number of other interesting programs out there, some of which have tried to move care out of the hospital and into the outpatient or home setting. As we continue to conceive of what constitutes high-quality, low-cost care and how to build that into our clinical pathways, we may see more changes in the common sites of care.