https://www.ajmc.com/journals/evidence-based-oncology/2019/pcoc-2018/oncology-payment-models
Oncology Payment Models

Coverage by Christina Mattina and Laura Joszt

Keeping Ahead of the Curve in the Transition to Oncology Value-Based Payment

At a session of Patient-Centered Oncology Care® 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.

Moderator Joseph Alvarnas, MD, started the discussion by acknowledging how keynote speaker Barbara McAneny, MD, had laid out a framework of challenges in balancing value and sustainability with better outcomes and patient experience. He asked the panel about the definition of value-based care, which he called “part platitude, part wastebasket.”

Although value-based care is “a hodgepodge of models,” explained Samuel Young, MD, MBA, CPE, senior medical director, Medicare Florida Blue, its core intent is to improve patient health outcomes and quality of life for patients at lower cost. Marcus Neubauer, MD, chief medical officer, The US Oncology Network, agreed with that assessment and added that value-based care arose because the current fee-for-service system is unsustainably expensive. Neubauer sees CMS as the major catalyst for the conversion to the alternative of value-based care and said that The US Oncology Network supports being part of that transition.

Circling back to the meeting’s theme, Michael Ruiz de Somocurcio, MBA, vice president, payer and provider collaboration at New Jersey–based Regional Cancer Care Associates, said that value must have the patient front and center because improving quality of care is not simply about checking a box. Fortunately, taking patient-centered steps like keeping patients out of the hospital has a ripple effect that improves care quality and lowers costs.

Complicating the matter is that the goal of improved outcome is defined differently for each patient, added James Helstrom, MD, MBA, chief medical officer, Fox Chase Cancer Center. Cancer type and stage will determine whether a patient is concerned with quality of life or is just trying to attain survival. Young agreed that there needs to be a condition-specific approach to measuring cost and quality.

Another issue, according to Young, is that incentives are misaligned from the patient, payer, and provider perspectives. Commercial plans have members who frequently change jobs and plans, meaning they may not reap long-term financial benefits after paying the up-front cost of a treatment, but they still want providers to act in the best interest of their patients.

Doing the right thing for patients is what actually led physicians in The US Oncology Network to become interested in value-based care before it became “trendy,” said Neubauer. They recognize they have a responsibility to manage cost of care and are taking steps to do so, leading him to conclude that any efforts to change culture must be physician led.

Helstrom agreed about the importance of provider-led change, saying that edicts from administrators automatically engender resistance. He suggested that by keeping costs out of the discussion and simply encouraging administrators to do the right thing clinically, cost reductions would typically follow. Ruiz de Somocurcio added that value-based changes must also fit within physicians’ workflow and should optimally be supported by hiring nurses, social workers, or patient navigators to alleviate physician burden.

Another “tremendous hurdle” to broader adoption of value- based care is full data exchange and transparency, said Young, which is hindered by the limitations of electronic health records. Having fully transparent 2-way data exchange will not only allow physicians to compare their cost and quality metrics with their colleagues’, allowing their competitive natures to drive improvement, but also would enable consumers to choose their providers on objective performance measures instead of word of mouth.

A discussion about value in cancer care could not omit drug prices, as Alvarnas mentioned the expensive new treatments that are resulting in better outcomes but also skyrocketing costs. Neubauer explained the role of providers in controlling drug costs; although they cannot promise payers that they will not use checkpoint inhibitors, they can commit to using them responsibly and identifying patients who are not likely to benefit.

Ruiz de Somocurcio offered a different perspective, saying that a focus on other low-hanging fruits is more likely to yield savings than uncontrollable drug costs. His organization is looking into the use of new biosimilars but is also identifying cost-cutting methods like reducing emergency department visits, performing office-based imaging instead of hospital-based scans, and using pathways to reduce variation in care.

Bringing the conversation back to the theme of the meeting, Alvarnas asked how the panelists work toward including patient goals in the value equation. Neubauer explained that his system has implemented treatment plans to formally outline a road map before starting treatment so patients and care providers can refer to it.

“In our transition to value-based care, I’ve seen patient experience improve,” Neubauer attested.

From the payer perspective, Young explained that as a custodian of members’ health data, his organization has launched data platforms that give patients a “virtual care community” that ties together patients’ life plans with opinions from their family members, social workers, and other stakeholders, allowing the care provider to access all of that input and bring it into the care discussion.

“Ultimately, this falls on us to bring together all these information sources so that everyone can see what’s best for the patient,” he said.

When Alvarnas asked the panelists to provide their final thoughts, each of them agreed that the shift to value is not going away. Ruiz de Somocurcio emphasized that value is here to stay, giving the example of the mandatory radiation oncology bundles announced by HHS Secretary Alex Azar on November 8, 2018.1 In terms of the larger shift toward value, Ruiz de Somocurcio said, “you don’t want to be last in line when that happens, so it’s time to do it now.”

REFERENCE:
Caffrey M, Inserro A. Azar announces mandatory oncology payment model is coming. The American Journal of Managed Care® website. ajmc.com/newsroom/azar-announc- es-mandatory-oncology-payment-model-is-coming. Published November 8, 2018. Accessed January 6, 2019.


Learning to Manage Data and Code for Comorbidities Is Critical for OCM Success

Data is of critical importance in the Oncology Care Model (OCM)—and CMS shares a lot of data with participating practices—but managing that data and using it to improve performance can be challenging, according to panelists at Patient-Centered Oncology Care®.

Typically, data can be difficult to access and integrate, explained Charles Saunders, MD, chief executive officer (CEO) of Integra Connect. He explained that some electronic health record (EHR) systems are better than others at giving up data, but most systems are not very good at all. Sometimes this is because EHR vendors are purposefully uncooperative and do not want to share information, but EHRs also were not built with data sharing in mind.

Saunders said that most practices do not have any experience in managing or understanding Medicare data, which is fairly high in quality. Aaron Lyss, MBA, director, value-based care, Tenessee Oncology, added that managing data is one of the areas in which his organization has probably made the most progress.

“The volume of claims data that we get through OCM is certainly at the outset daunting, like drinking from a firehose, but over time it’s become an incredible asset to our organization,” explained Lyss.

Seeing and managing the claims data has given Tenessee Oncology a better understanding of policy issues of payment models and given the practice more confidence in participating in these models, Lyss said.

René Frick, senior director, network innovations and partnerships, BlueCross BlueShield of South Carolina (BCBSSC), noted that her company has a lot of claims information but that the payer is trying to integrate with practices to get clinical data and view the full picture of care. Another challenge is that even when the payer provides practices with data they seek, those practices do not always know what to do with the information to improve care.

BCBSSC has 8 practices participating in OCM, including Carolina Blood and Cancer Care (CBCC), where Kashyap Patel, MD, is the CEO.

One of the things BCBSSC has found is that patients are going outside their regular practices to the emergency department (ED). According to Patel, CBCC has been focusing on reducing ED visits, hospitalizations, and number of days in the hospital. Frick added that these are areas BCBSSC is looking at with most of its practices, because they are aspects the practices can control. These were some of the low-hanging fruits that CBCC focused on, and now it is focused on indexing comorbidities.

Recording morbidities and Hierarchical Condition Category (HCC) codes is crucial for success in OCM, explained Saunders. CMS sets the practice target price based on a risk model that includes HCC coding, but oncologists tend to undercode patients. Integra’s analysis found that in 27% of cases, oncologists were recording just 1 HCC code or comorbidity and that in 17% of cases, there were no HCC codes or comorbidities at all.

“That means in over 40% of the cases, it’s either 0 or 1, and for a [patient with] lung cancer who’s between the ages of 65 and 85, you know that’s not realistic,” Saunders said. “That means that their target price is set inappropriately low, so it’s not surprising they can’t achieve that target price.”

Patel said that his practice created small laminated cards that list the common comorbidities and HCC codes, and each physician was given multiple cards to keep in their coat pocket, at their house, in their office, and anywhere else. But it remains a challenge, he admitted. Every week, physicians in the practice meet and improve but will then start to forget to record the comorbidities. 

Doing a better job of coding is one of the many cultural changes required in OCM, the panelists agreed.

“I think the behavior change in physicians has been a chal- lenge,” Patel said. “I have to say my team is very well organized, very cooperative...but, including me, we have [been] programmed [and] we have to decondition ourselves and, really, recondition to look at this value-based care.”

At Tenessee Oncology, the practices show the physicians how they are all performing so there is transparency in the organization. For physicians who want to improve their performance, one-on-one meetings are available, Lyss explained.

“It’s kind of old-fashioned, but I think it’s worked well,” Lyss said.

Although Saunders acknowledged the cultural transformation that the practices represented on the panel had undergone, he noted that such transformation has been variable across the country. He outlined the difference between 1 practice with more than 200 oncologists that had been able to invest in infrastructure to achieve success and compared it with a smaller practice that did not have that capability and was so busy taking care of patients that the physicians could not become experts in Medicare or the model.

However, he also highlighted the differences Integra has seen between community-based and health system–based practices.

“Surprisingly, or maybe not surprisingly, the communi- ty-based ones are doing a better job of controlling the costs than the hospital-based ones,” Saunders said. “And we see ones [in which] there is a big difference between those that use organized care pathways [and] ones that don’t.”

The panelists concluded by discussing what is next in the OCM, which is scheduled to eventually shift to 2-sided risk. Originally, the model called for 20% downside risk, which is the stop-loss limit, but CMS recently brought the risk down to 8%. Although that is better for practices, Lyss said it was the difference between “completely absurd to 50% as absurd but still absurd.”

That said, Tenessee Oncology has been meeting frequently since CMS announced the change, and the practice believes that the economics of the new arrangement look better not just for Tenessee Oncology but for many of the practices. The organization has figured out that if it just matches its current perfor- mance, it will stand to do better in the 2-sided risk arrangement.

However, for many practices, the stop-loss adjustment is not enough, Saunders acknowledged.

“It’s still a level where if you really think your practice is going to get anywhere near that stop-loss, you’re not going to do that 2-sided risk arrangement,” he concluded. “It’s just a nonstarter.”
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