Quality Programs

Marin Specialty Care (MSC) sets the Bar for Quality—a Brief History


Everyone would agree that quality is a vital characteristic of medical care.  We’d also agree that we trust our care-givers to provide quality care to us.  What most of us do not appreciate is that there is no on-going evaluation of quality in most out-patient care settings, let alone in cancer care.

The establishment of standards in our practice and the ability to assure ourselves, the professional staff of MSC and our patients and their families, that we provide such care, has been a driving force for us for many years.

Beginning in 1978, when our practice was established, we participated in National Cancer Institute-sponsored clinical trials which assured us “that the care we provided was the very best know at that time.”  We continue to offer our patients such studies to provide the best standard treatments and potentially better treatments with the new agents and techniques we study.

In 1989, we were instrumental in founding the Association of Northern California Oncologists (ANCO), which was established to support practicing oncologists in offering excellent care.  Three of our physicians have served as its President, and four of us have served on its Board.  ANCO now represents over 240 oncologists in Northern California – the vast majority of the practicing physicians caring for patients with malignant illnesses.

In the mid-1990s, our practice was accredited by the Accreditation Association of Ambulatory Health Care (AAAHC), the first oncology practice in the country to be so designated.   The AAAHC is the largest accrediting body of outpatient facilities recognized by Medicare.

We didn’t stop there.  In 1995, we convened a meeting of 60 Northern California oncologists to study the feasibility of merging practices and establishing standards.  While there was significant interest in this proposition, there was not much spirit of compromise, and in the end, three small practices merged to form California Cancer Care, MCC’s predecessor..

At that meeting, several experts on the quality of medical care described the new discipline of cancer quality initiatives and advised us to start measuring outcomes in our practice.  A friend who advises public hospitals on quality improvement urged us to “start measuring things and to keep doing so”—supporting the notion that improvement occurs when systems are merely observed (the Hawthorne Effect.)

We took their recommendations seriously and began to keep records of all sorts of things, describing them to various academic health service researchers.

At the same time, the 1999 Institute of Medicine report, Ensuring Quality Cancer Care pointed out a number of glaring deficiencies in the cancer care delivery system, noting that “The NCPB has concluded that for many Americans with cancer, there is a wide gulf between what could be construed as the ideal and the reality of their experience with cancer care.

“Based on the best available evidence, some individuals with cancer do not receive care known to be effective for their condition.”

A year later, Enhancing Data Systems to Improve the Quality of Cancer Care was published, describing the woefully inadequate system of record-keeping most physicians employ, and challenging providers to do better.  Marin Oncology Associates, one of CCC’s predecessors, was lauded for “using data for quality monitoring purposes.”  It said:

“Launching a quality assurance program using only internal resources is unusual for a small group of private practitioners, but Case Study 1 (see box) provides an example of one such initiative.  Barriers to quality monitoring identified by members of this small practice included high costs, limited staff resources, a lack of incentives, an absence of an accepted set of quality measures, and a lack of benchmarks or standards with which to gauge success (P. Eisenberg, physician, Marin Oncology Associates, Inc., personal communication, October 18, 1999).

According to the practice physicians, the program has been effective in aligning the practice with accepted practice guidelines and in demonstrating the value of the group practice to managed care organizations and insurers (P. Eisenberg, personal communication, October 18, 1999).”

These IOM reports can be read online, respectively, at http://books.nap.edu/catalog/6467.html and at http://books.nap.edu/catalog/9970.html.

Our interest in quality was recognized by the American Society of Clinical Oncology (ASCO), and we have participated as a member of the Health Services Committee on and off for the past 20 years.

Using the data we compiled, we presented or findings at the 2001 annual meeting of ASCO, the largest organizations of oncology professionals in the world—over 26,000 members.  We explained our system of retrospective analysis and shared the podium with an insurance company executive who challenged other practices to do the same so that they might benefit by increased reimbursement.

Based on our willingness to examine our practice patterns and to establish standards to which we hold ourselves, we have negotiated favorable contracts with a number of payers.  They recognize that few practices spend the time and resources on tracking the care they provide and want to keep us on their panels.  They further appreciate that adherence to guidelines and the development of standards of care are likely to improve patient satisfaction while reducing costs.

MSC’s Role in Quality Projects

MCC members have continued to play important roles in establishing standards and defining quality in cancer care.  Here is what we have been doing:

  1. The Georgia Cancer Coalition asked the Institute of Medicine to help them reduce cancer deaths in the State of Georgia.  The Coalition wanted to develop outcomes and accountability measurements to monitor Georgia’s progress in improving cancer care and reducing overall cancer-related morbidity and mortality.  Dr. Eisenberg participated as a member of the Institute of Medicine’s committee to develop the benchmarks and indicators needed for success.Eden J, Simone JV, Eds. (Eisenberg PD, Committee member) “Assessing the Quality of Cancer Care: An Approach to Measurement in Georgia. A Report of the National Cancer Policy Board of the Institute of Medicine.” Washington, DC, National Academy Press, 2005. This can be found at http://www.nap.edu/books/0309095697/html/
  2. The National Quality Forum (NQF), with support from the National Cancer Institute (NCI), the Agency for Healthcare Quality Research (AHRQ), Centers for Medicare and Medicaid Services (CMS), and Centers for Disease Control and Prevention (CDC) undertook a project to address the need for national standards for measuring quality of care that would result in information useful to patients, providers, and other stakeholders.  Dr. Eisenberg was a member of the project’s Steering Committee (2002 to 2005) which developed a framework for cancer quality measurement and a work plan for the project.  More information is available at http://www.qualityforum.org/activities/home.htm
  3. The NCI’s Cancer Redesign (CaRe) Planning Group to lay out a plan for “an idealized design for cancer care” met in March, 2004 in Bethesda.  The NCI wishes to articulate a framework and strategy for a larger project to improve the care of patients with cancer.  This high-level NCI group will brainstorm about how one would completely restructure the system of cancer care. It is assisted in this endeavor by Don Berwick, M.D. and the IHI. Dr. Eisenberg participated as a member.
  4. The Agency for Healthcare Research and Quality (AHRQ), CMS and NCI, sponsored an expert meeting, on October 18 and 19 on “Transforming Health Systems through Leadership, Design, and Incentives.”  Dr. Eisenberg participated with a “select group of health system leaders who worked together to examine the feasibility of making design changes within the current financial and regulatory environment.  Ways in which the payment systems (and particularly those run by CMS) might be changed to facilitate good design and promote quality and efficiency more broadly were considered.”
  5. A consortium of the National Committee for Quality Assurance (NCQA), Kaiser Permanente and Intermountain Health Care invited our practice to participate in an effort to develop and evaluate quality of cancer care measures that can be used by the NCQA and organized health care systems.  A central goal of this project is to develop measures that can be used for on-going performance improvement and accountability purposes.  Dr. Eisenberg is participating as a member of an ASCO/NCQA committee.
  6. We partnered with the University of California at San Francisco Institute for Health Policy Studies to address issues of quality.  A team of clinicians and researchers examined what actually constitutes high-quality care by addressing questions such:
    • What are the best ways to ensure that clinicians employ the best-available medical evidence?
    • How can we ensure that patients’ preferences and feelings about treatment are acknowledged and respected?
    • What are appropriate ways to recognize and reward healthcare providers who provide high quality care to their patients?
    • This project is funded with research grants from Ortho-Biotec and United Healthcare.

  7. Dr Eisenberg participated in an NCI workshop, “Opportunities for Management Science & Engineering in Improving Cancer Care Delivery” on August 31, 2010.
  8. Dr. Eisenberg is a member of the UnitedHealth Group Physician Advisory Committee, which will provide expert physician guidance on the creation of programs to evaluate, report on and improve clinical quality.
  9. The ASCO Board established a “rapid response team” for quality issues, the Quality Advisory Group (QAG.)  Dr. Eisenberg participated with Chairperson, Patti Ganz, Joe Simone, Deborah Schrag, Deborah Kamin, Ellen Stovall, Jose Jacobson, Mike Neuss, Ezekiel Emanuel, and Joseph Bailes.  Its purpose is to respond quickly to issues regarding quality that are time-sensitive.  QAG subsequently became the Quality of Care Committee (QCC), a standing committee, a permanent ASCO committee.
  10. Dr. Eisenberg was interviewed and contributed to “Issues and Opportunities for Transparency of Oncology Reporting in California: Findings from Expert Interviews,” prepared for the California Healthcare Foundation in December, 2010.

MSC’s On-Going Quality Projects

We all agree that cancer is a leading cause of death and disability in the United States and a significant area of healthcare spending. Providing high-quality cancer care is an important national priority. However, relatively little is known about what doctors and patients actually mean by “high-quality cancer care.” Even less is known about how to configure our healthcare system so that it recognizes and rewards high-quality care.

  1.  Dr. Eisenberg and Harvey Bichkoff, MSC’s CEO have been helping United HealthCare define standards for quality oncology care.  Dr. Eisenberg is Chairman of the United HealthCare Oncology Physician Advisory Board. UHC is the country’s second largest health insurance company and wishes to establish a network of oncology practices to which they will send the majority of their patients for cancer care. These practices will be credentialed and approved to provide excellence in cancer care.
  2. Our CEO, Harvey Bichkoff, MPH, is a surveyor for the AAAHC and California Medical Association’s Institute for Medical Quality (IMQ).  As a surveyor, he audits HMOs, multi-specialty groups and surgery centers to determine if they meet state and national quality standards. He is a member of the IMQ’s Ambulatory Care Review Committee, which reviews survey report forms to determine accreditation decisions.
  3. ASCO’s Quality Oncology Practice Initiative (QOPI) (see http://qopi.asco.org/) under the direction of Joseph Simone, M.D. (http://SimoneConsulting.com/), has developed a web-base program to define and measure quality.  The primary purpose of this effort was to determine the feasibility of establishing a sustainable model system to promote high-quality cancer care that may be easily integrated into practice.This project has received lots of attention from payers, including CMS, BC/BC and United HealthCare.  The American Board of Internal Medicine has determined that QOPI participants will be waived from the requirement to establish a Practice Improvement Module for board re-certification.

    We at MSC were one of the “Alpha Group,” and helped establish the program and continue to refine the outcome measures and methodology. Dr Eisenberg is a member of the QOPI Steering Committee.

  4. Other projects:
    1. MSC’s physicians, nurses, nurse practitioners and professional staff are committed to pursuing their goal of providing the very best care possible. To this end we implemented MOSAIC, an oncology-specific electronic medical record
    2. develop tools to guarantee quality at the point of service, rather than by retrospective review.
    3. continue to participate in the many regional and national efforts underway to improve the quality of cancer care as described by the National Cancer Policy Board:
      1. Dr. Eisenberg is a member of the Guest Faculty of the Clinical Excellence Research Center (CERC) Fellowship Program of Stanford University, which provides post-doctoral students an opportunity to gain knowledge, skills, and experience developing innovative health care delivery models that improve patient health and lower annual per capita health spending.
      2. Dr. Eisenberg was a participant in a conference sponsored by the California HealthCare Foundation and the Coalition for Compassionate Care, “Palliative Care Continuum,” May 22, 2012, to discuss and explore what can be done in California to promote the development and expansion of palliative outside of the acute care setting.
      3. He participated in a collaboration of the California HealthCare Foundation (CHCF) and the Integrated HealthCare Association (IHA) to explore ways to effectively and meaningfully measure the quality of cancer care.  We will look at how data from the California Cancer Registry (CCR) might be leveraged with commercial claims data and other sources (e.g. OSHPD data) to measure cancer care quality broadly in the state.  This is a (8-10 participant), informal, brainstorming session to discuss possibilities and challenges. October 23, 2012.
    4. Dr. Eisenberg participated in the Institute of Medicine’s, National Cancer Policy Forum, “Delivering Affordable Cancer Care in the 21st Century,” October 8 & 9, 2012.  The goals of the workshop include:
      1. Summarize current evidence on the overuse, underuse, and misuse of medical technology throughout the continuum of cancer care;
      2. Identify problems in the system that could be modified, and suggest changes to address them; and
      3. discuss policy issues related to the value, cost containment, and reimbursement of cancer care as well as the economic incentives of innovation and technology diffusion in cancer.
      4. The workshop will include a series of presentations and panel discussions examining the causes of rising costs in cancer care and will suggest potential ways to curb these costs while maintaining or improving the quality of care. The workshop will facilitate a dialogue among stakeholders in oncology care to determine the potential paths forward.
    5. Our practice has a UC Berkley MPH Graduate Student Intern the summer of 2013.  She is working with Dr Eisenberg to define further indicators of quality oncology care and benchmarking our practice against published work.