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High-Impact Workflow Changes for Value-Based Care Success

Charles Saunders, MD; Charles Alcorn, MS; Catherine Cowan, MSN, RN; and Maria Fabbiano
As oncology practices transition to value-based care, they are challenged to take on more holistic responsibility for their patient. Fortunately, the examples of practices participating in CMS’ Oncology Care Model can offer valuable insight into the most impactful workflow changes providers can implement as they strive to achieve cost and quality improvements.
Value-Based Care Drives Practice Transformation

In this era of value-based care, oncologists are becoming increasingly accountable for achieving improvements in cost, quality, and experience across their patient populations. This expectation is at the foundation of measures introduced by CMS through both the Merit-based Incentive Payment System (MIPS) and the Oncology Care Model (OCM) alternative payment model programs—with commercial payers following suit. It is essential to the financial viability of oncology practices that they perform well against these evolving rules. At stake is a swing in reimbursement of 28% or more.1 The precise rate depends on the value-based care programs that practices choose and their performance, relative to peers, on the required measures.

These new innovative payment models challenge oncologists to assume an unprecedented degree of responsibility for their patients’ entire episodes of care. However, this is a departure from the way most practices have traditionally operated, and nothing short of clinical, financial, and operational transformation will be needed to succeed. The OCM anticipated this and provided its road map in the form of 7 mandatory pillars of practice transformation, from enhanced patient access and evidence-based treatment guidelines to the introduction of care management.2 It then attempted to mitigate the infrastructure and investment requirements through Monthly Enhanced Oncology Services payments aligned with episodes of care on a per member per month basis.

A North Star for Success

Despite these guide posts, many practices have struggled with where to start and how to prioritize the highest-impact interventions, understandably so, given the number of potential focus areas and the uncharted territory in front of them. An emerging group of OCM participants has coalesced around a common vision to guide their transition to value-based care—increasing direct control over the 3 primary drivers of cost and quality that impact patients:
  • Avoidable emergency department (ED) visits. These are often triggered when a patient with an acute complaint cannot access their oncologist and goes (or is directed) to the hospital instead. Our review of CMS data spanning a wide range of OCM practices during a period of 3.5 years found that a single ED visit ($729.67) costs nearly 6 times more than an average office visit ($124.67) and often results in an admission.
  • Unnecessary inpatient admissions. Usually these result from patients presenting at the ED and clinicians admitting them based on an incomplete picture of their conditions and treatment. Our data show that nearly half of ED visits resulted in an admission that cost an average of $9797.
  • End-of-life care. This becomes important when a patient in an irrevocably advanced disease state continues to receive treatment without an awareness of other options for care. Multi-pronged programs to support seriously ill patients with case management, advanced care planning information, and tools—in the form of government and community resources—have resulted in substantial improvements in patient experience and cost. For example, Aetna’s Compassionate Care Program3 yielded a 3-fold increase in the hospice election rate, which not only fueled higher patient satisfaction, but reduced acute days by 82%, ED visits by 75%, and intensive care unit stays by 86%.
How can practices most effectively move the needle against these pitfalls of cost and quality? While there are many options for interventions and supporting decisions to be made along the way—staffing models, clinical protocols, and resources—the connective tissue is work flow. Specifically, 4 core work flow changes are being pursued by early leaders in the OCM program, enabled by new technologies:
  1. Identifying and stratifying patient populations on an ongoing basis
  2. Employing targeted care coordination and management
  3. Improving patient access to appropriate levels of care
  4. Deploying end-of-life and supportive care programs
Identify and Stratify Patient Populations on an Ongoing Basis

To reduce costs and improve outcomes, oncologists must begin by identifying and targeting their highest-risk patients and practices must simultaneously deliver programs that prevent low- or moderate-risk patients from becoming high risk. Therefore, practices must have the capability to risk stratify all patients in their panel on a timely and regular basis, not only at the outset of OCM or MIPS participation.

For the typical oncology practice panel, there is a powerful correlation between risk and cost. Analysis of our data acquired from a wide range of OCM practices nationwide demonstrates that 20% of patients account for as much as 50% of total healthcare costs. Many of the costs for the highest-risk group of oncology patients result from emergency medical admissions, 30-day readmissions, and skilled nursing facility stays following hospitalization—a large percentage of which are potentially avoidable.

Few oncology practices have the technologies, skills, and capabilities to undertake this effort on their own. Several leading OCM practices are tackling this challenge by employing sophisticated algorithms and multi-variable statistical models from Integra Connect.

Developed using regression or machine learning techniques, or both, these models account for patient-specific factors, such as:
  • Cancer type
  • Comorbidities
  • Use of chemotherapy agents with serious
  • adverse effects
  • Number of chemotherapy agents
  • Functional status
The result has been grouping patients into risk cohorts based on their likelihood of having 1 or more potentially avoidable high-cost events. Only then can practices predict the likelihood of adverse events and design effective interventions in a less-costly, lower-acuity setting such as the office itself.

However, these leaders are converting measurement and management into an ongoing workflow tied to the core operations of their practices. Why?

A patient’s risk profile may change very quickly with the advancement of their cancer or the addition or change of a chemotherapeutic agent, with serious side effects. Therefore, patients must be risk stratified as early as possible at the start of an episode of care or when their cancer is first diagnosed and treated with one or more chemotherapeutic agents. The stratification must then be updated on a regular basis to ensure it accurately reflects the most current status of the patient’s health.

Establishing this work flow relies on consistent access to a wide variety of data—clinical, financial, and social—that must be scrubbed, identity-matched, and semantically normalized to enable “whole” patient views that support subsequent analysis for predictive risk.

Employ Targeted Care Coordination and Management

With their highest-risk patients identified, practices can effectively target them with proven interventions. Care management is a long-standing concept that, until the advent of value-based care among practices, was associated with health insurers in the managed care industry. Its premise was that care activities that occurred in between office visits, such as telephonic outreach for a follow-up or a status check with patients and/or their caregivers, would proactively allow for early identification and resolution of health and socioeconomic issues that could result in unnecessary utilization of costly services, such as the ED or hospital, if left untreated.

Now, with value-based models requiring a whole patient approach, some OCM practices are rapidly developing effective and efficient care management and navigation capabilities. Although oncologists and their clinical staff may have performed some elements of care management in the past, these actions were secondary to their traditional role, which is managing the patients’ specific chief complaint in an office-based setting. The nature of fee-for-service reimbursement encouraged this episodic approach to care and discouraged activities outside of the office encounter. Now, OCM practices are organizing and sta ng dedicated care management programs and integrating them into high-risk patient work flow. Their keys to successful transformation have included:
  • Recognizing that care management activities are complex and contain new responsibilities that require time and resources to execute well; they cannot simply be added to the workload of a practice’s existing staff
  • Ensuring sufficient staffing to achieve the desired results, with capacity driven by the number of patients being managed in the context of their clinical risk, behavioral health needs, and socioeconomic factors, which are strong predictors of utilization
  • Developing a staff mix of licensure levels (registered nurse, licensed practical nurse, certified medical assistants, social worker, etc) to allow staff to operate at the top of their license in a team-based approach to care, which contributes to an efficient and cost-effective care management program
  • Utilizing an application/program that provides required tools for assessment, care planning, intuitive patient care management activities, and communication with the patient’s interdisciplinary care team.
To understand the positive clinical and financial effects of care management, consider the following example from an OCM practice. A care navigator contacted an 80-year-old man with a diagnosis of prostate cancer for a regularly scheduled follow-up status check. She found that the patient was not planning to fill his prescription because he could not afford it. The care navigator, with the patient, contacted a patient advocate and obtained financial assistance so the patient could pay for his medication and become compliant. Without this intervention, the lack of adherence might not have been identified until symptom progression.

Improve Patient Access to Appropriate Levels of Care

Care management represents a new and proactive workflow for many practices. Care teams must also transform their daily routines to react more efficiently and effectively to unforeseen events.

One critical dimension of these efforts is ensuring patient access to the appropriate level of care at the appropriate time. Previously, provider access was dictated by the standard work week: the open hours of the physical office setting. Yet, patient concerns arise 24 hours a day, 7 days a week.

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