ALBUQUERQUE, N.M. -- Over the years, oncologist had grown increasingly frustrated with what hospitals were doing to her patients.
Every time chemotherapy complications sent someone to an emergency room, which happens all too often, "they'd come out a little bit worse, each time just another step down in their quality of life."
They'd sometimes contract other infections while waiting for hours for the cause of their fever or diarrhea to be diagnosed. And if admitted, they'd grow weaker and disoriented lying in a bed.
The longer they wait for their first dose of antibiotics, the more likely they will become septic and end up in the intensive care unit, she said.
If only she could keep them away from hospitals.
So she and her 15-physician team at the New Mexico Cancer Center changed the way they practiced. In 2006, they initiated office-based "shot clinics" on weekends to boost her patients' white cells.
Later, they launched other services she said oncology practices don't usually offer, like weekend and nighttime hours, same-day appointments, even walk-in visits. They worked harder to recognize complications earlier, and in so doing group lowered costs and reduced hospital ER visits. They scheduled patients' appointments for them, and helping them manage their medications.
(See related story of one patient's experience).
The key, however, is the triage pathway McAneny wrote for trained nursing staff to distinguish serious medical issues like a heart attack, for which someone should be in a hospital, from early-stage complications from chemotherapy.
"You sound like you're having chest pain because you have bronchitis ... you've been coughing all night and now your ribs are kind of sore," she said. "We can fix that. You can come here. And you don't have to wait.
"Our patients, when they go to the ER, they sit next to some guy with pneumonia for eight hours, and then my guy's got pneumonia too."
Skinny and Bald
"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.'"
In 2012, the Center for Medicare & Medicaid Innovation (CMMI) gave her $19.8 million to prove her model could work for 26,000 Medicare patients in seven practices around the country from Maine to Albuquerque.
She called the 3-year program . And, she said, so far it's proved a success.
McAneny said an by the National Opinion Research Center, prepared for CMMI, found that among patients enrolled for 2 years in Come Home, it $224 per enrollee per month. It avoided 10 emergency room visits per 1,000 patients per quarter, and three hospitalizations.
Data from one of the seven Come Home sites, operated by the New England Cancer Specialists in Maine, found a 2-year cost reduction of nearly $20,000 per patient, compared with similar cancer patients in Maine, according to a by the American Society of Clinical Oncology.
Since the goal was to reduce hospitalizations, not surprisingly the biggest difference was in inpatient costs, which were reduced by $6,195. Fees for services to providers outside the oncology practice like surgeons or primary are doctors dropped nearly $5,000 per patient.
McAneny wasn't the first oncology practice to use a model of care designed to avoid the hospital and lower costs. Some commercial plans like United Healthcare and Aetna have their own programs.
But McAneny was the first to test the model in a federal demonstration for a large population of Medicare beneficiaries with cancer, who are more complex because of their age and comorbidities. Half of all cancer patients are .
former administrator for the Centers for Medicare & Medicaid Services who now directs the Margolis Center for Health Policy at Duke University, was part of the team that helped to develop the (OCM) for CMS, which in 195 practices began July 1. (See related story describing the OCM model.) He said Come Home's "unique combination of features" and extensive evaluation allowed Medicare to incorporate key aspects of Come Home into the OCM.
"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 as a result," he said.
And on Nov. 1, the American Society of Clinical Oncology announced a with Come Home, an effort it said would use McAneny's model to prepare oncology practices to comply with MACRA (Medicare Access and CHIP Reauthorization Act of 2015) starting Jan. 1.
ASCO Come Home gives practices tools to "identify and manage symptoms in real time, improve access to providers through same-day appointments and extended night and weekend hours," and improve symptom recognition.
deputy chief medical officer for the American Cancer Society, also said the Come Home improved patients' quality of life. Although he noted that one analysis he'd seen, some of the sites achieved more success than others.
One difficulty in analyzing Come Home's results is in measuring mortality or survival. That's tough because patients were enrolled with different kinds and types of cancer and in different stages, and that data was hard to collect and analyze.
"The biggest lesson that we learned from the Come Home model, said , executive director of Community Oncology Alliance, which represents cancer specialists, "is that we can do a much better job of keeping patients out of the hospital, out of the emergency room, from being readmitted to the hospital."
the Brookings Institution, who also worked on the OCM model with McClellan, said there's "no doubt" Come Home is "a great model," but she worries that McAneny had to spend too much on infrastructure to get the project going. "The ability to scale her model is the biggest challenge," she said in an email.
Models Built Around Hospitals Don't Save
Long active in the American Medical Association, McAneny, who is running next year for strongly believes that care improvement models should center around doctors, not hospitals.
In 2010, just after the Affordable Care Act passed, she found herself in a meeting with Dr. Richard Gilfillan, then director of the $10 billion CMMI. He was complaining that models designed to save money over the years had failed.
"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,' " McAneny said.
According to a 2010 for every 1,000 commercially insured patients undergoing chemotherapy, there are 929 visits on average to the emergency room and 378 inpatient admissions. By McAneny's estimate, chemotherapy patients have up to a two-thirds chance of being admitted.
But many don't need to be there. A decade ago, 25 to 40 of her 3,500 cancer patients were hospitalized during a weekend. Now, it's more like 10 or 15, including patients there for stem cell or bone marrow transplants that can't be performed in her office.
McAneny's model was challenged by unexpected walk-in patients with complications that turned out to be much more serious than the team could handle, said New Mexico Cancer Center chief operating officer Nina Chavez.
That necessitated the creation of a rapid response team that would immediately transition the patients to a hospital.
Saving $18 Million
McAneny and several hospital organizations have not seen eye to eye. Last year, she accused an Albuquerque hospital of trying to sabotage Come Home by sending a mailer saying that cancer patients with chemotherapy symptoms should go directly to that hospital. The hospital denied the accusation.
And before that, she told 番茄社区, she was trying to persuade Albuquerque's Presbyterian Health Plans that it should subsidize some of her triaging expenses. By managing patients' complications in her practice instead of the much costlier hospital, she avoided $18 million a year in hospital costs the health plan didn't have to spend, she said.
Her arguments fell flat. "The problem was, the health plan is part of the same corporation as the hospital," she said. The health plan executive saw that $18 million as revenue that McAneny had "stolen" from the hospital corporations. They wanted those patients in their hospital, not in McAneny's practice, she said.
In essence, according to McAneny, Presbyterian viewed her practice and her ambitions to expand its range of services as a competitive threat.
McAneny ultimately responded by filing against Presbyterian's three business units because, she said, "this hospital and its health plan and employed physicians group were working very hard to put us out of business." Presbyterian is the dominant hospital system in Albuquerque, and McAneny charged that it had actively discouraged its physicians from referring patients to her clinics, even offering "financial rewards" to physicians who don't make such referrals. And the system's health plan has refused to reimburse services provided by McAneny's practice at a level she can afford, she said.
, an attorney representing Presbyterian, denied McAneny's allegations. He said one part of McAneny's claim against Presbyterian's hospitals has been dismissed. He declined to comment further on the record, but Presbyterian has filed a .
Come Home for Other 番茄社区
McAneny lately has been talking up her program to non-oncology practices as a way to adopt their services for alternative payment models under MACRA.
A few weeks ago, she touted Come Home to the California Medical Association in Sacramento, and last month, at a National Committee for Quality Assurance in Washington, D.C. She's seeking the council's accreditation as a MACRA-qualified medical home.
"Anybody who is managing chronic diseases with acute exacerbations can use a triage model like mine to manage patients, even diabetes or heart failure," keep patients alive longer, in their own homes, and reduce costs and patients' co-pays, McAneny said.
Of course, some patients will always need to be in hospitals, as costly and risky as they tend to be.
"There always will be cancer patients in the hospital. But not so many of them. And if I can keep them out, they do better," she said.