When health plans encourage doctors to improve quality by comparing their performance with the best-practice guidelines that medical associations champion, physicians will often respond, “How?” As in how will they find the time and/or resources to manage this?
Blue Cross Blue Shield of Michigan responds by giving doctors money. That’s the idea behind the insurer’s working with 180 oncologists in 11 physician groups caring for about 16,000 patients. The plan pays the doctors $3,000 each to pull charts and compile information on cancer care. That information is then added to the database maintained by the American Society of Clinical Oncology (ASCO).
“It’s the first time that such a large and coordinated effort in a single state is using a national database to promote excellence in cancer care and, at the same time, rewarding physicians for these improvement efforts,” says Robert Chapman, MD, director of the Josephine Ford Cancer Center at Henry Ford Medical Group, one of the participating practices.
The program allows oncologists to quickly tap into ASCO’s cancer treatment data on tens of thousands of patients. The insurer, which plans to spend about $500,000 on the program this year, hopes that this will encourage the sharing of information in the field of oncology.
The $3,000 is used to cover the cost of a physician joining ASCO and an oncology practice’s tapping into the Quality Oncology Practice Initiative (QOPI), ASCO’s database, according to David Share, MD, MPH, the health plan’s senior associate medical director of health care quality. Oncologists participating in BCBSM’s Physician Group Incentive Program are asked to join ASCO if they are not already members. The oncology practices will register for ASCO and submit data twice a year to ASCO’s QOPI database, which can also be described as a registry. The ASCO registry draws information from about 385 oncology practices in the country.
“The oncology practices get the data, BCBSM doesn’t,” Share explains. “The physicians assess their practices against national standards. They examine the extent to which there is variation in practice. Then they take that learning and use it to guide improvement in systems of care. What they report to BCBSM is the processes they engage in, the learning they derive from the information, and the actions they take to alter practice and improve quality and efficiency.”
For instance, pain assessment is a big part of the QOPI. Three questions patients are asked are
- Were you asked to rate your pain, in terms of percentage, by the second office visit?
- Was the intensity of your pain, in terms of percentage, quantified by the second office visit?
- If you are a patient with moderate to severe pain, were you given documentation that your pain was assessed?
“Oncologists participating in the ASCO QOPI initiative will receive information back from ASCO about how their office practices compare nationally to their peers,” says Share. “They will be provided aggregate information on whether they did or did not assess pain at a random sampling of their patient visits. Oncologists and their partners will be able to take this information and modify their care processes.”
The information being collected focuses on chemotherapy planning and side effects, pain assessment and control, and specific measures related to the management of colon and rectal cancer, non-Hodgkin’s lymphoma, and non-small-cell lung cancer.
The bottom line here is improved clinical outcomes, though the insurer admits that there may be some savings as well.
“BCBSM spent $784 million for oncology-related services in 2006, which was 10 percent over the previous year and the largest area of expenditures,” says Share. “Comparative performance reports regarding concordance of practice patterns with generally accepted standards of care have been successfully used to guide efforts to improve quality in other areas of care. These efforts have often been associated with improvements in the efficiency of care as well.”
Share admits that he doesn’t know if this will be the case in cancer care, but it’s worth a try. “There are potential opportunities, such as optimizing efficiency of use of blood cell stimulating agents and targeting new, high-cost anti-cancer agents to those patients with evidence of potential benefit, for example B Herceptin for those who have relevant cell receptors.”
To take another example, information gathered on how to prevent dehydration caused by chemotherapy could reduce the number of hospital admissions.
Data collection began in May, and BCBSM officials say that they will not know the exact savings for about 18 months, although early results may be released this month.
Oncologists and BCBSM officials worked for about a year and a half, reviewing possible means for improving cancer care in the state. “After considering dozens of options, the team decided the best starting place is the ASCO quality measure system,” says Share.
In many ways, it was stepping into uncharted territory. “It isn’t known how much variation there is in community-based cancer care practice nor how much opportunity there is to increase concordance with evidence-based practice or to achieve cost savings while doing so,” says Share. “But cancer is all too common and cancer care is both challenging for patients and costly. It makes sense to first learn whether there are opportunities for improvement and then to act on them. Since health care is complex and evolving, there is every reason to think that cancer care can be improved, as is true of any complex human endeavor.”