Attributes of high-value oncology, primary care identified
Two novel Stanford studies have uncovered attributes of high-quality, low-cost care for cancer and primary care patients.
Mounting pressure on U.S. physicians to control skyrocketing health care spending has led to a demand to understand how to provide the best possible care at the lowest possible cost.
Now, two overlapping teams of researchers at the Stanford University School of Medicine have identified tangible changes that physicians can make to meet goals to improve the value of health care specified by the Medicare Access and CHIP Reauthorization Act of 2015 and reinforced by private health insurers. Beginning in 2019, Medicare payments to physicians will be adjusted up or down by annually increasing amounts according to how a doctor meets national benchmarks for high-value care.
In two separate studies, the researchers outline several tangible attributes of cancer care and primary care that will allow physicians and their teams to rise to this challenge.
“No one has ever conducted this type of research in physician office sites before,” said Arnold Milstein, MD, professor of medicine at Stanford. “These studies are unprecedented, not only in what they examined, but in their potential to affect the practice of medicine on a national level.”
“Cancer care is expensive, and physicians and insurers sometimes question the value of the nonmedical or nonclinical services that we provide for patients,” said Douglas Blayney, MD, professor of medicine. “Here, we identify for the first time specific aspects of high-quality, low-cost care that provide value for patients and payers and that can be adopted by doctors and organizations across the country.”
Blayney is the lead author of the cancer-care study, which was published Nov. 16 in JAMA Oncology. Milstein is the senior author of that study, as well as the senior author of the study that identified the distinguishing features of high-value primary care practices, which was published online Nov. 13 in Annals of Family Medicine.
Milstein is the director of Stanford’s Clinical Excellence Research Center, the first university-based research center exclusively dedicated to discovering, testing and evaluating cost-saving innovations in clinically excellent care. Blayney is a member and the former medical director of Stanford’s Cancer Institute.
Digging into national data
For both studies, the researchers used never-before-available claims data from insurance companies to identify physician-practice sites across the country that deliver high-quality care with less total health care spending.
The oncology study analyzed data from thousands of cancer patients at oncology sites throughout the Pacific Northwest and Midwest from January 2007 to May 2014; the primary care study analyzed commercial health insurance claims from 2009 to 2011 from more than 40 million patients and 53,000 primary care practice sites.
The researchers then compared the average annual total health care spending per primary care patient or spending per cancer treatment episode at each of the high-quality care sites. Practice sites that ranked at the top of both measures (delivering both high-quality and low-cost care) were designated as high-value sites for further study.
The researchers then conducted extensive site visits of high-value and average-value physician practices to tease out attributes of care that distinguished high-value sites — sites that deviate positively from the norm.
“We wanted to understand what’s different about the care of the high-performing clinical teams that allows them to lower the cost of excellent care, which is an aspiration of both Congress and of private insurers,” said Milstein. “These studies are the first to distinguish attributes of physicians who provide great, more affordable care.”
Three broad themes capture the distinguishing features of high-value U.S. cancer care: an early discussion with each patient of the limitations, expectations and goals of cancer care; the early involvement and normalization of palliative care — not just for end-of-life issues, but also to help alleviate or manage treatment side effects; and a dedicated outpatient facility for cancer patients to address their urgent care needs in an ambulatory care setting.
A fourth attribute — the presence of a go-to point person, often a nurse or a nurse practitioner, to help patients problem-solve difficulties around self-care and navigate a sometimes confusing health care system — was also important, the researchers found.
“Our findings suggest that many of the places that provide high-value care are also particularly good at providing these often unreimbursed, nonmedical services,” said Blayney.
Shepherding each primary care patient
A similar concept, identified as “care-traffic control,” was one of the takeaways from the study of high-value primary care sites. “We found that physicians at these sites were thinking more deeply about what each individual patient needs to navigate in the periods between primary care office visits,” said Milstein. “Does their illness affect their executive functioning? Are they following through on laboratory tests? Are they taking their medicines as prescribed? Are all of the doctors and specialists a patient sees aware of important aspects of their care plan, such as the existence of an advance directive? Although this is unknown territory to physicians in average-performing primary care practices, it is actively surveilled and supported by their high-value peers.”
We found that physicians at these sites were thinking more deeply about what each individual patient needs to navigate in the periods between primary care office visits.
Other important themes in primary care include the use of treatment protocols — for example, standing orders supported by electronic health care records to ease the cognitive burden on the care staff — and a system to ensure that the compensation packages for physicians and care staff members reflect the quality and affordability of the care they provide.
“No one has ever studied this intersection of high-quality and low-cost health care at a national level for individual physician offices,” said Milstein. “We’re hopeful that these studies will help American physicians and policymakers better understand what tangible changes in care-delivery practices will allow physicians to meet our national thirst for more with less.”
“Our research uses the concept of positive deviants to uncover existing solutions to health care challenges that can be adopted by clinicians around the country to produce similar results,” Blayney added.
The studies are examples of Stanford Medicine’s focus on precision health, the goal of which is to anticipate and prevent disease in the healthy and precisely diagnose and treat disease in the ill.
Other Stanford co-authors of the JAMA Oncology paper are Melora Simon, MPH, a former project director at the Clinical Excellence Research Center; former visiting instructor Beatrice Podtschaske, PhD; former research coordinator Margaret Shyu; and visiting scholar Craig Lindquist, MD, PhD. A researcher from the Hutchinson Institute for Cancer Outcomes Research also contributed to the paper.
Other Stanford authors of the Annals of Family Medicine paper are Simon and Julia Murphy, former project leader at Stanford’s Clinical Excellence in Research Center . Researchers from Harvard Medical School, Case Western Reserve University School of Medicine and QuintilesIMS also contributed to the study.
Blayney has consulted for the Michigan Oncology Quality Consortium, is a volunteer leader of ASCO’s QOPI program and is a consultant for and stockholder in PRM/CARET. Simon has an immediate family member who is employed by and is a shareholder of Guardant Health Inc.
The research in both papers was supported by the Peterson Center on Healthcare.
Stanford’s Department of Medicine also supported the work.
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