Climbing the "Severity Ladder": Avoiding the first steps.

In recent posts, I emphasized two realities that matter deeply for community oncology teams. First, you cannot navigate every patient, and surface indicators such as HCC scores can mislead if used as blunt triage tools. Second, the events that drive navigation and triage are not abstract; they come through phone calls, patient portal messages, and the front desk when a worried patient shows up without warning. Third, when you extrapolate the real cost of emergency department ("ED") visits and inpatient stays for oncology and hematology patients, it becomes clear that navigation and triage are not soft services; they are direct levers of cost avoidance in value-based care.

🎯 The Shift from Volume to Value in Oncology

Community oncology practices and hospital-based groups face the same external pressure: deliver high-touch cancer care while absorbing more financial risk. The transition from fee-for-service to value-based care is not a simple change in payment models. It requires rewiring daily operations, redefining roles, and building the capability to respond to real-time patient needs.

Cancer symptoms escalate quickly and unpredictably. Side effects emerge abruptly. A seemingly low-risk patient can become a high-cost case within hours. This is why value-based oncology must be grounded in operational readiness, not retrospective risk scores.

To illustrate scale:

• Average oncology ED visit cost: $2,900

• Average oncology inpatient day: $4,500

• Typical oncology length-of-stay (“LOS”): 5 to 7 days

• Resulting inpatient episode: $22,500 to $31,500

• Hematology/Oncology high-acuity episodes: $35,000 to $40,000 or more

Each avoidable inpatient admission is a measurable impact on the practice's total cost-of-care benchmark.

📞 Where Patient Need Becomes Evident

Most high-cost episodes do not begin with structured assessments. They begin with an event:

• A call to the triage line

• A portal message describing new symptoms

• A patient walking in without an appointment

• An after-hours escalation to on-call staff

  
  

Real patient risk emerges from real-time operational signals, not static scores.

🧭 Navigation vs Triage: Distinct Roles, Distinct Value

Navigation drives patient experience and access. Triage drives cost avoidance and safety. When combined into a single role, both functions degrade.

📊 Quality Metrics vs Value-Based Care Metrics

Practices often confuse quality metrics with value-based performance metrics. Both matter but they serve different purposes.

Quality protects clinical integrity. Value-based metrics protect financial sustainability.

🏥 Operationalizing Navigation and Triage for Value-Based Care

Successful practices focus on three operational pivots:

1. Create a two-pathway model: navigation and triage separate but connected.

   This design ensures that clinical acuity receives immediate attention while navigation resources stay focused on barriers that affect adherence, access, and patient experience.

   
   

2. Use real-time events as risk triggers.

   Calls, portal messages, walk-ins, and after-hours escalations are leading indicators of avoidable acute care use. Programs that staff triage lines with oncology-trained nurses consistently reduce ED use by 10 to 15 percent.

   
   

3. Direct navigation to where it matters most.

Not every patient requires a navigator.

💡 A Practical Example

A community oncology practice with 1,000 chemotherapy patients typically sees ED visit rates of 10 to 12 percent per year. That equates to roughly 120 ED visits, each costing about $2,900. Roughly 20 percent of ED visits progress to inpatient admission.

This produces:

• $350,000 in ED spend

• $600,000 to $900,000 in inpatient spend

• $1 million in total potentially avoidable cost

What makes this even more challenging is the day-of-week pattern commonly seen in oncology admissions. Admissions tend to spike late in the week and into weekends. These are exactly the times when clinics are closed, staffing is thinner, and the threshold for sending patients to the ED drops significantly. The result is a higher proportion of ED-to-inpatient conversions, longer lengths of stay, and more admissions that roll into the next week.

For a value-based practice, this weekend effect can increase preventable inpatient spend by hundreds of thousands of dollars if not actively managed.

Installing a same-day oncology triage line staffed by experienced nurses, paired with targeted navigation follow-up, can reduce avoidable ED visits by 10 to 15 percent. The financial return is immediate and typically visible within the first year of a value-based contract.

📌 Key Takeaways

1. Real patient risk appears through real-time events, not static risk scores.

2. Trigger navigation follow-up after every triage interaction.

3. Each avoidable oncology inpatient stay has a large financial impact.

4. Navigation and triage must be separated operationally to be effective.

5. Quality metrics preserve clinical excellence. Value-based metrics preserve financial performance.

6. Practices that modernize triage pathways see measurable reductions in acute care utilization.

7. Standardize response pathways for fever, dehydration, pain, and GI symptoms.

8. Review performance data weekly or monthly.

   • How many navigation and triage calls occurred

   • How many required escalation

   • How many ED visits were potentially avoidable

   • What patterns emerged in portal messages and walk-ins

References

1. Health Care Cost Institute. Emergency Room Spending, Price, and Use Trends. HCCI; 2021.

2. Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs: Emergency Department Visits. AHRQ; various years.

3. Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey (NHAMCS): Emergency Department Summary. CDC; 2022.

4. Kaiser Family Foundation. Hospital Adjusted Expenses per Inpatient Day. KFF; 2023.

5. Agency for Healthcare Research and Quality. HCUP National Inpatient Sample (NIS) Database Documentation. AHRQ; 2022.

6. Centers for Medicare and Medicaid Services. Medicare Inpatient Prospective Payment System (IPPS) Final Rule and Impact File. CMS; FY 2024.

7. National Cancer Institute–Designated Cancer Centers. Public Quality and Outcomes Reports on Inpatient Oncology Care. NCI; accessed 2024.

8. Oncology Nursing Society. Telephone Triage for Oncology Nurses: Guidelines and Protocols. ONS; 2022.

9. Academy of Oncology Nurse & Patient Navigators. Navigation Metrics Toolkit. AONN+; 2021.

10. Schnipper JL, Colvin CM, Rao SR, et al. Patient telephone call patterns and symptom triage needs in oncology. J Oncol Pract. Published studies informing symptom-call distributions.

11. Centers for Medicare and Medicaid Services. Oncology Care Model (OCM) Performance-Based Payment Methodology. CMS; 2021.

12. Centers for Medicare and Medicaid Services. Enhancing Oncology Model (EOM): Model Overview and Requirements. CMS; 2023.

13. Weaver SJ, Rosen MA, DiazGranados D, et al. Weekend effect in hospitalized patients: admission day, length of stay, and mortality. BMJ Qual Saf. 2015;24(9):572-582.

14. Woodhouse JB, Gibson L, Slade E, et al. Day-of-week variations in hospital admissions and outcomes. Health Serv Res. 2020;55(2):268-279.

15. Milliman and Avalere's analytic frameworks for acute-care avoidance in oncology. Industry Modeling Standards for Value-Based Care. 2023.

16. Porter ME, Kaplan RS. The cost of care delivery in oncology. Harv Bus Rev. 2016;94(6):60-70. (Cited for episode-cost construction logic.)