Driving Value-Based Practice Transformation Through Care Management

In Fresno, California, a woman receiving ongoing cancer treatment shared with her clinical team that she was feeling lightheaded following her infusions.

Although the patient’s reported adverse effects were common for her treatment protocol, her care team at California Cancer Associates for Research & Excellence (cCARE)¹ asked her a few questions that revealed she faced food insecurity. cCARE’s patient navigator enrolled her in Meals on Wheels and addressed this issue, improving the trajectory of her ongoing care.

Between 17% and 55% of Americans with cancer face food insecurity² like the patient from Fresno, placing them at elevated risk for adverse events during treatment and higher mortality rates.³ Food insecurity is just 1 example of a variety of circumstances that can result in missed care, hospitalizations, and negative clinical outcomes for people with cancer. Such factors are detrimental not only for patients but also for community practices. Data presented at the American Society of Clinical Oncology Annual Meeting in 2023 show that 51% of emergency department visits by patients with cancer between 2012 and 2019 were unplanned and preventable.⁴

As a result of these trends, community oncology has moved away from fee-for-service and more toward value-based care—prioritizing value over volume—over the last several years. At its core, value-based care aims to improve outcomes and reduce costs. However, over time, value-based care has become synonymous with payment models such as the Oncology Care Model (OCM) and subsequent Enhancing Oncology Model (EOM). These payment models place significant administrative challenges and downside risk on practices and have subsequently had low uptake.⁵

Unlocking the value of care management models

While joining risk-bearing payment models may not be viable for some community practices, value-based practice transformation is possible for most through iterative care management approaches. Care management elevates patient care while generating new pathways to reimbursement for outstanding care already being provided. Implementing a care management program can serve as an achievable first step for community oncology practices seeking to deliver value-based patient care in their current fee-for-service arrangements.

Existing care management approaches, such as Principal Care Management (PCM), Transitional Care Management (TCM), and Principal Illness Navigation (PIN), focus on an aspect of value-based care and serve as an on-ramp to broader patient-centric practice transformation.

PCM encourages regular, proactive outreach to patients and time-based reimbursement, while TCM reimburses practices for prompt episodic care planning following adverse events. PIN reimburses community oncology practices for their efforts to identify and address social determinants of health.

The initial phases of any shift to a care management model require practices to develop workflows and infrastructure to track progress. Establishing both workflow and infrastructure using models such as TCM, PCM, or PIN demonstrates to payers and accountable care organizations that a practice can sustain patient-centric care management models—and, in turn, value-based care—without prematurely accruing downside financial risk.

Practice transformation is not one-size-fits-all

Rather than jumping headfirst into value-based payment models, cCARE and other Navista practices across the country are working to identify and implement care management approaches that optimize existing advantages at their respective clinics. By considering the patient population, data, staff capacity, and local hospital and health system relationships, each factor plays an important role in determining a realistic plan for implementing care management at each practice.

For example, Rocky Mountain Oncology, located in rural Wyoming, had a close relationship with its local hospital and had providers who rounded there, providing an opportunity to implement TCM.

As part of its TCM implementation, Rocky Mountain Oncology learned that a patient had been admitted to the hospital with fever and chills. Upon discharge, the patient received a prompt follow-up from Rocky Mountain Oncology. The practice saw her within 24 hours, identifying a chemotherapy reaction as the underlying issue, and adjusted her medication to avoid further hospitalizations.

Without the prompt follow-up involved in TCM, patients are at risk of readmittance. One study of advanced cancer patients found that lack of timely follow-up was the second most likely cause of readmission.⁶

While TCM can be incredibly valuable for some practices, it might not be the right choice for others. For example, Cancer Care of North Florida (CCoNF) in Lake City, Florida, is in a market with several hospitals and primary care practices with well-established TCM programs. Considering the specific nuances of the Lake City market, the practice maximized its highly engaged nursing staff and implemented PCM.

CCoNF nursing staff and providers established a workflow for proactive outreach to patients and an infrastructure to track time spent conducting check-ins, scheduling appointments, and answering questions. The outreach soon made a difference for 1 patient receiving long-term treatment who hadn’t visited the clinic in a while. Thanks to outreach prompted by PCM, the care team was able to get the patient seen quickly, potentially mitigating negative outcomes from delayed care.

For other practices, particularly those with a diverse patient population, there may be more impactful ways to deliver meaningful clinical improvements. In Fresno, many cCARE patients face social and/or economic circumstances that affect treatment, such as the patient facing food insecurity. Left unaddressed, underlying social, economic, and environmental barriers to care result in delayed treatment and poorer outcomes.⁷

To better identify and address social determinants of health, cCARE patient navigators implemented PIN at the large, multidisciplinary practice. One patient presented to the cCARE patient navigator team unable to find transportation to regular appointments. Through PIN, the navigation team connected the patient to a transportation service and received reimbursement for the entire care coordination process.

Small, purposeful steps to a value-based care future

As oncology continues to move toward patient-centric, outcomes-driven care, value-based payment models are not the only way to reach this destination. The path to value-based care delivery should be iterative, intentional, and measured to ensure sustainable change while clearly demonstrating progress to payers. Community oncology practices are already doing care coordination. Care management models and related codes available in fee-for-service simply provide the scaffolding for practices to demonstrate their value to the market.

With front-end training and small shifts with a deep understanding of a practice’s unique market, staff resources, and patient population, community oncology can methodically evolve care delivery and drive the future of community cancer care.

Author Information

Mike Fazio, head of value-based care at Navista, is an industry authority with firsthand experience in value-based care payment models, risk-based arrangements, managed care contracting, and payer-provider relationships. Fazio helps alliance member practices implement value-based care through a consultative, technology-driven approach. Previously, he was senior vice president of client services for Archway Health (now part of Coverys).

References

1. California Cancer Associates for Research and Excellence (cCARE). Accessed April 10, 2026. https://ccare.com/
2. Raber M, Jackson A, Basen-Engquist K, et al. Food insecurity among people with cancer: nutritional needs as an essential component of care, J Natl Cancer Inst. 2022;114(12):1577–-583. doi:10.1093/jnci/djac135
3. O’Connor JM, Sedghi T, Dhodapkar M, Kane MJ, Gross CP. Factors associated with cancer disparities among low-, medium-, and high-income US counties. JAMA Netw Open. 2018;1(6):e183146. doi:10.1001/jamanetworkopen.2018.3146
4. Tabriz AA, Turner K, Hong YR, Powers BD, Lafata JE. Trends and characteristics of potentially preventable emergency department visits among patients with cancer in the US. J Clin Oncol. 2023;41(suppl 16):e13643(2023). doi:10.1200/JCO.2023.41.16_suppl.e13643
5. Perzigian A, Zunker GL. Contributor: Why hasn’t value-based care delivered on its promise at scale? AJMC. April 4, 2024. Accessed April 13, 2026. https://www.ajmc.com/view/contributor-why-hasn-t-value-based-care-delivered-on-its-promise-at-scale-
6. Johnson PC, Xiao Y, Wong RL, et al. Potentially avoidable hospital readmissions in patients with advanced cancer. J Oncol Pract. 2019;15(5):e420-e427. doi:10.1200/JOP.18.00595
7. Abdullah A, Liu Z, Molinari M. From diagnosis to survivorship: the role of social determinants in cancer care. Cancers (Basel). 2025;17(7):1067. doi:10.3390/cancers17071067