Alternative Payment Models

Dan Mendelson, MPP, founder, Avalere Health, discusses how the shift to value-based care has impacted managed care pharmacy.

While the Oncology Care Model is likely not a sustainable mode for oncology care, it will probably inform what payment structure comes next.

Years before the Oncology Care Model (OCM) was implemented, Northwest Medical Specialties started preparing by making changes to the personnel in the practice, explained Sibel Blau, MD, medical oncologist at Northwest Medical Specialties, PLLC.

In fiscal year 2019, there will be approximately $1.9 billion in value-based incentive payments available to hospitals in the Hospital Value-Based Purchasing (VBP) Program, which is a budget-neutral program.

The lag time between the end of a performance period in the Oncology Care Model (OCM) and the release of the full report from CMS, represents a challenge for practices looking to improve.

CMS is moving home health agencies away from a volume-based payment model and to a new value-based payment system. The Patient-Driven Groupings Model would focus on patient needs and rely more heavily on patient characteristics in order to pay for home health services.

The proposed changes to the Medicare Shared Savings Program may put a damper on the accountable care organization (ACO) movement, but ACOs remain the government’s best option for controlling healthcare costs, said Stephen Nuckolls, CEO of Coastal Carolina Quality Care.

There are some proposed changes to the Medicare Shared Savings Program (MSSP) that may be favorably or not depending on the accountable care organization (ACO) and its situation, said Allison Brennan, MPP, senior vice president of government affairs for the National Association of ACOs.

Chronic diseases remain a significant challenge for older Americans, and Humana is using a holistic approach, leveraging value-based reimbursement models, to improve health outcomes and quality measures for the insurer’s Medicare Advantage (MA) members, according to a new Humana report, “The Intersection of Health + Care.”

Practices that had experience with the COME HOME community oncology medical home model didn’t perform any better in the Oncology Care Model (OCM) than other practices, explained Barbara L. McAneny, MD, president of the American Medical Association.

In the keynote address at Patient-Centered Oncology Care® 2018, Barbara McAneny, MD, a New Mexico oncologist/hematologist and the current president of the American Medical Association (AMA), shared her diagnosis for the current crisis in US healthcare, as well as a prescription—a new real-time oncology payment model led by physicians.

At a session of The American Journal of Managed Care®'s Patient-Centered Oncology Care® 2018 meeting, held November 16 in Philadelphia, panelists shared their views on the future of oncology value-based payment models and how they as payers and providers can help advance these models.

This week, the top managed care news included research that showed c​​​​ancer surpassed cardiovascular disease to be the leading cause of death in high-income counties; HHS Secretary Alex Azar announced a new mandatory payment model is coming to oncology; a policy change could make mental health treatment more available.

CMS' announcement of a new mandatory oncology bundled payment model wasn't a surprise. It reinforces CMS' continued commitment to creating innovative ways of transforming care.

Data and collaboration are necessary ingredients to succeed in the transition to value-based care models, and the money saved under these models will create room to pay for unconventional therapies and services in healthcare, according to panelists at The Institute for Value-Based Medicine meeting in Seattle, Washington.

The shorter timeline to risk and the reduction of shared savings rates are among the 2 greatest challenges accountable care organizations (ACOs) will face as part of the proposed changes to the Medicare Shared Savings Program (MSSP), said Allison Brennan, MPP, senior vice president of government affairs for the National Association of ACOs.

While the proposed changes to the Medicare Shared Savings Program (MSSP) won’t mean a large number of changes to Coastal Carolina Quality Care, the accountable care organization will have to make some changes to respond to the new Enhanced track, said Stephen Nuckolls, CEO of Coastal Carolina Quality Care.

According to a review published in Cancer Management and Research, biosimilar products present a viable cost-saving tool for providers participating in value-based care programs such as the Medicare Shared Savings Program or the Oncology Care Model.

The proposed changes to the Medicare Shared Savings Program could prevent the program from driving broad change to value-based care across the country, according to Katherine Schneider, MD, MPhil, FAAFP, president and CEO of Delaware Valley ACO.

To speak about the success and continued development of Priority Health's payment reform model in cancer care, John Fox, MD, medical director at Priority Health, joined Dennis Zoet, chief business development officer at Cancer and Hematology Centers of Western Michigan, on a panel at the Community Oncology Alliance Payer Exchange Summit.

Oregon has approved new policies to continue the transformation of its Medicaid program with a focus on behavioral health, value, and social determinants of health in the state's coordinated care organizations.

There are different ways to measure how Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) have saved money, and the way used can drastically affect the amount of savings reported, explained Clif Gaus, ScD, president and CEO of the National Association of ACOs.

Systems, groups, and practices that haven’t yet joined the accountable care organization (ACO) movement will find it harder to do so if the proposed changes to the Medicare Shared Savings Program (MSSP) take effect, said Rob Fields, MD, assistant profession, family medicine and community health, Icahn School of Medicine at Mount Sinai, and senior vice president, chief medical officer, population health at Mount Sinai Health System.

The Community Oncology Alliance (COA) has been working with its member practices and some payer partners who have successfully implemented innovative care delivery and payment models to develop a 2.0 version of CMS’ Oncology Care Model (OCM). A progress report was presented at COA’s Payer Exchange Summit held October 29-30 in Tyson’s Corner, Virginia.

While practice transformation is vital, community-based clinics continue to struggle with emergency department (ED) use, hospitalization, and risk stratification as they identify ways to reduce unnecessary expenditures within their Oncology Care Model (OCM) practice.

Lalan Wilfong, MD, moderated a conversation between Robert E. Baird, MD, CEO of Dayton Physicians Network, and Sarah Cevallos, chief revenue cycle officer for Florida Cancer Specialists and Research Institute, about current and future strategies for Oncology Care Model (OCM) participation, as well as key lessons from the OCM and how they can be applied in other reform models.

The proposed changes to the Medicare Shared Savings Program (MSSP) acknowledge the complexity of the program and bring more predictability and stability to MSSP, according to Katherine Schneider, MD, MPhil, FAAFP, president and CEO of Delaware Valley ACO.

Practices that did not meet cost-savings goals in either the first or second performance periods of the Oncology Care Model (OCM) will likely leave the program, said Barbara L. McAneny, MD, president of the American Medical Association.

The proposed risk adjustment changes to the Medicare Shared Savings Program (MSSP) are welcome but moving accountable care organizations (ACOs) to risk too soon could harm the program, said Stephen Nuckolls, CEO of Coastal Carolina Quality Care.

Approximately one-third of all US healthcare payments in 2017 were tied to alternative payment models, with the remaining still tied to fee for service. The findings of the Health Care Payment Learning and Action Network report highlighted that even as payments move to value-based models, more spending in models with risk is needed.