Oncology CM vendor improves cancer care

Result is healthier patients, lower costs

When the quality management and quality improvement teams at Blue Cross and Blue Shield of Missouri examined the data for each disease, they found that the costs for oncology were increasing at a much greater rate than for other diagnoses and that the increases were exceeding 10% a year.

"It got our attention right away," says Sharon Hoffarth, MD, medical director for quality management who supervised the implementation of the oncology management program of Blue Cross and Blue Shield of Missouri. The oncology management program is a specialized utilization management program with a strong oncology case management component.

The health plan’s quality management and quality improvement sections look at the ICD-9 codes for each disease annually and divide them into "buckets" to compare cost trends from HMO and PPO members, Hoffarth says.

When the oncology costs began soaring, the team starting looking for reasons and ways to improve the situation.

Like other case managers, the health plan case managers were mostly generalists with little or no specialized training to manage oncology patients.

When oncology certification requests came in, the nurse case managers and their physician advisors often had to research any new procedures or practices before making a certification determination.

"Because of the difficulties of wanting to make the right decisions for our members, it wasn’t good for our members and it wasn’t good for the network providers," Hoffarth says.

The company chose Quality Oncology of McLean, VA, to handle its oncology management program. The program was launched in the fall of 2002. About 2,100 members are expected to be eligible.

Quality Oncology handles utilization management and case management for members with cancer who are 18 years of age and older. Members have 24-hour-a-day access to a team of cancer nurses.

"The case management side is where we find the real value of our contract with Quality Oncology. Their nurses have five to 10 years of experience in oncology and are familiar with all the difficulties that cancer patients face," Hoffarth says.

For instance, cancer patients often need help with pain management, hydration, nutrition, and infection. A significant number face end-of life issues.

"The Quality Oncology nurses are excellent at coordinating care and helping our members with cancer stay as healthy as possible. Because potential problems are recognized earlier, these members have a better quality of life and are at lower risk of being hospitalized for complications associated with cancer therapy. The result is healthier members and lower medical costs," Hoffarth says. The biggest bonus has been the decrease in inpatient admissions, she notes.

"We’ve seen dramatic results. The approach to oncology management is not rocket science. It’s getting people who know the terrain in touch with the patients and basically nipping any potential problems in the bud," Hoffarth adds.

Nurses with oncology experience know what can go wrong and recognize early on when a member may be developing a problem, she adds.

The oncology nurse case managers talk to members about their diet, nausea, pain, and other concerns. Based on their conversations, they may tell the members to call the physician if the situation indicates.

For instance, if a patient is vomiting and can’t keep his medications down, the oncology case manager will advise him to see the physician, possibly heading off a trip to the emergency department.

"The Quality Oncology nurses are very good at coordinating hospice care. They not only help the physician in arranging care, but they make it the best situation for the member and the member’s family," Hoffarth adds.

The oncology program has benefits for oncologists, too. The certification denial rate for oncology services provided by Quality Oncology is lower than the overall denial rate — 2% compared with 5%, she says.

If a certification nurse gets a request to certify some kind of treatment that falls outside oncology treatment guidelines, they refer the quest to the Quality Oncology physician advisor. The physician advisor, who is a board-certified oncologist, immediately calls the treating oncologist to discuss the request and work out an acceptable treatment approach.

Referrals are generated from trigger reports based on ICD-9 and CPT codes, and in some cases come in on the regular certification line.

"Generally, if the utilization management certification nurse suspects cancer, we turn it over to Quality Oncology right out of the gate to work with the member’s provider," Hoffarth says.

For instance, if someone is admitted for stomach pain, the case manager knows he or she needs to keep an eye out for the first signs that it may be an oncology case, she adds.

Prior to the programs launch, some network physicians expressed skepticism about the merits of the program. Since the programs has gone on line, the network oncologists seem to appreciate the service, Hoffarth adds.

In the first month of the program, a local oncologist called to suggest other Blue Cross Blue Shield of Missouri members who were not currently in active treatment. They thought these members would benefit from oncology case management.

Because the Quality Oncology nurses are oncology-trained nurses and the physician advisors are oncologists, they know what the treating physicians and their office staff are talking about, Hoffarth points out.

Before the insurer starts a new disease management program, they get input from the members of their physician network.

When they started the oncology case management program, they invited network oncologists to attend meetings held throughout the health plan’s area of coverage with the corporate medical director and the Quality Oncology medical director to discuss any concerns.

"We value very highly the collaborative relationship we have with our physician network. We’ve worked very hard over the past six or eight year to include physicians in our planning process and to get to the point where our physicians feel they can work with us. We want to maintain an open door for our network doctors, Hoffarth says.