If a community oncology practice wants to embrace value-based care, how can it get started?
Three physicians who helped build value-based programs from the ground up shared their experiences—and what they might do differently—in a lively fireside chat to conclude the first day of the 11th Annual Patient-Centered Oncology Care® meeting, held November 9-10, 2022, in Nashville, Tennessee.
Led by Lalan Wilfong, MD, a longtime physician with Texas Oncology who is now vice president of payer relations and practice transformation at The US Oncology Network, the panel also featured Sibel Blau, MD, president and CEO of the Quality Cancer Care Alliance network and medical director, Oncology Division, of Northwest Medical Specialties in Puyallup, Washington; and Stephen M. Schleicher, MD, MBA, chief medical officer of Tennessee Oncology.
Wilfong invited Blau and Schleicher to share key lessons from their experiences with value-based care. Blau said the 2 most important takeaways were the importance of data and analytics and the need for cultural change within a practice. “Without the participation from everyone—not just physicians—and understanding the financial impact of changing the mindset,” practice transformation will not work, she said. Moving away from the idea that practices will not make money from administering drugs—and in fact may lose money in some cases—is a tall order.
For value-based care to work, Wilfong said, practice leaders must shift their mindset and pair financial success with changing practice patterns. “It takes a lot,” he noted.
Schleicher agreed with the need to shift a practice’s culture, but said it can be done in a way that makes it seem “cool.” He concurred with Blau that cultural change must extend from the top physician leaders to the person at the front desk, with the goal being to change the view that if a patient ends up in the emergency department (ED), “which is going to happen, that somehow we failed.”
Building the team will start small and then grow as the practice learns who should be involved in creating a patient-centric culture, Schleicher said. He pointed to members of his own team involved in data analytics and revenue cycle management and, of course, nurses and physicians.
Wilfong shared his experience with shifting practice culture. “One of the biggest lessons we learned is that you have to have a mindset of quality,” he said. “You really can’t change your practice until you have that mindset—where you bring in a team, you’re bringing in the data, you’re bringing in that culture change [and] figuring out what problems you want to solve and how…you iteratively improve upon [that].”
At Texas Oncology, where Wilfong worked on quality improvement before his current role with The US Oncology Network, the early focus was on reducing ED visits and hospitalizations. It was a challenge, because Texas Oncology had many sites of service, including satellite clinics, and the reasons for too many ED visits might vary from site to site—from staffing, to not answering phones, to other reasons.
“It was very interesting how we had to really think through on a location by location basis how to solve that problem,” Wilfong said. Texas Oncology instituted a quality improvement initiative that reduced ED visits, and continues to improve on the results.
Schleicher said the value-based care movement calls for practices to learn from each other. For example, if Schleicher sees a paper from Wilfong and The US Oncology Network team, he shares it with the Tennessee Oncology team.
Getting started. When Tennessee Oncology began its journey in value-based care, Schleicher said, “the biggest challenge was knowing where to start.”
As with other practices, reducing ED visits was an early focus for Tennessee Oncology. But that means getting the data, and that is not always simple. As data accumulate, Schleicher noted, the areas of focus emerge, and the team grows as it becomes clear who needs to be in the room.
Blau said her practice took note of early models, such as the COME HOME project in New Mexico, as it made steps into value-based care.1 As her practice learned some things, “I’ve been sharing information.”
It wasn’t easy. Early on, during the Oncology Care Model (OCM) implementation,2 4 physicians left Blau’s practice, which created extra work for the remaining partners. “That was, honestly, a big challenge,” she said. But culture change does happen, as physicians understand that changing their behavior affects patient outcomes.
“It took a while to get there, [and] it depends on how big your practice is,” she said. The number of physicians can make a difference—her practice operations manager called the process of engaging multiple physicians “herding butterflies.”
For Blau, creating buy-in among the staff involved educating every person on why they are in health care. “Everyone has such an important role in what we do in oncology,” she said, and it was essential for each person to understand how their role affected patient care. “Once they buy into it, it all falls into place.”
Using MEOS effectively. When the OCM began in 2016, participating practices received Monthly Enhanced Oncology Services (MEOS) payments, which were $160 per patient per month during each episode. These payments were a double-edged sword at first, Wilfong said. MEOS payments were provided by CMS to set up delivery of data-collection, navigation, and other enhanced services required under the model—but according to Wilfong, some physicians viewed this strictly as new revenue, and they had to be taught what was required to accept the payments. Wilfong asked the group to discuss how they might use MEOS differently, knowing what they know now.
“The data are so important,” Blau said, noting that her practice invested in 2 different analytic tools and that she would have put even more focus on the data if she started today. From today’s vantage point, she said having even more clinical case managers to process this information and put it into action would have been wise. For all the talk about electronic patient reported outcomes (ePROs), Blau said that without a good system to process them, “they are horrible.”
Schleicher pointed out that there were many years of “trial and error” until Tennessee Oncology settled on an 8-person team that works with care management, triage operations, and data infrastructure. (In the final year of the OCM, Tennessee Oncology received a perfect score on its quality rating from the Centers for Medicare & Medicaid Services.3) “It makes it hard now to imagine not having the MEOS,” he said, although Wilfong noted that after June 30, 2022, MEOS payments ceased as the OCM expired.
Blau and Schleicher each credited a nonclinician member of their respective teams—Amy Ellis, now chief operating officer for Northwest Medical Specialties, and Aaron Lyss, MBA, now director of Strategic Payor Relations at OneOncology—with grappling with the financial and quality elements early in the process. Tennessee Oncology now has a core team led by Leah Owens, DNP, RN, executive director of care transformation.
If he could go back to the beginning of the OCM, Wilfong said, “I would have spent half of it on technology and data and half of it on staff. Because I think you need a combination of those people to succeed in the model.”
The challenge now, he continued, is that practices committed to value-based care have operated without MEOS payments since the OCM expired, and are looking ahead to reduced payments when the Enhancing Oncology Model starts July 1, 2023.4 “I know a lot of practices are struggling with, ‘Do we keep this additional staff or not?’ It’s hard, because you recognize how much better care management will be for your patients, but you’re not compensated for it.”
Finally, he said, a key element of success for The US Oncology Network was having a drug strategy.5 “We had to have a drug strategy in order to financially succeed,” Wilfong explained. “And so, we align our drug strategy with our values, and help drive success.”
1. The COME HOME model. Come Home Program. Accessed January 22, 2023. http://www.comehomeprogram.com/index.php/come-home-practices/
2. Oncology Care Model. CMS Innovation Center. Updated November 18, 2022. Accessed January 22, 2023. https://innovation.cms.gov/innovation-models/oncology-care
3. Tennessee Oncology receives perfect quality score while saving Medicare $5 million during last year of Oncology Care Model. Tennessee Oncology. November 20, 2021. Accessed January 22, 2023. http://bit.ly/3lAe7w0
4. Enhancing Oncology Model. CMS Innovation Center. Updated January 18, 2023. Accessed January 22, 2023. https://innovation.cms.gov/innovation-models/enhancing-oncology-model
5. Staggs S, Ginsburg A, Garey J. The efficient use of data can drive savings and quality care. Healthcare Business Today. October 29, 2022. Accessed January 22, 2023. https://www.healthcarebusinesstoday.com/the-efficient-use-of-data-can-drive-savings-and-quality-care/