Washington, DC—Transforming an oncology practice into one that incorporates value involves several key elements, including improved collaboration and coordination among the treating physicians and team building, said Diana Verrilli, Vice President and General Manager, Managed Care, Quality and Provider Solutions, McKesson Specialty Health, The Woodlands, TX, at the Sixth Annual Conference of the Association for Value-Based Cancer Care.
Although new payment models, like the Centers for Medicare & Medicaid Services (CMS) Oncology Care Model (OCM), emphasize quality in a shift toward value, from the payers’ perspective, incentives also exist to reduce avoidable medical spending and decrease the total cost of care. All value-based payment models whether clinical care pathways or care management, episode-based payment, or the oncology medical home focus on the total cost of care.
Physicians now must care “about what happens outside of their office, and be much more focused on what happens to the patients when they leave that office, and what’s likely to happen in terms of downstream utilization,” said Ms Verrilli.
She spoke of the experience at The US Oncology Network, where 80% of members are covered under value-based agreements. “When we think about this in the context of the Oncology Care Model, our world has really changed, at least in The US Oncology Network,” she said. “We think about the overall goal to advance and have better care, smarter spending, and healthier people.”
To accomplish this goal, oncologists must have a broad vision that encompasses the entire care continuum.
Episodes of care under the OCM are defined as 6 months of chemotherapy treatment. Every Medicare beneficiary who is covered under a fee-for-service arrangement is eligible to participate in the OCM. There are 2 forms of payment under the OCM, including a monthly fee of $160 per beneficiary, which “barely covers the practice transformation efforts that are required to support the program,” Ms Verrilli said. The second form of payment is a shared-savings performance-based payment to incentivize practices to lower the total cost of care.
The total healthcare expenditures under the OCM will be calculated after the first administration of chemotherapy or the fill date for oral chemotherapy prescriptions. Physicians will have an especially challenging time to monitor the fill rate unless the prescription is filled at a network pharmacy.
Transforming a Practice into an Oncology Care Model
Ms Verrilli spoke about assessing a practice’s readiness to transform into a value-based practice, especially fulfilling the provider requirements to participate in the OCM. “Not all practices are ready for this,” she said. “If they are on a fee-for-service system, they’ve been on that their entire careers, moving to this is really herculean, and it requires a lot of focus within the organization.”
The first assessment involves a gap analysis to understand the current state of the practice with regard to the OCM requirements. In this gap analysis, individuals will identify opportunities to support the transition from a volume-based to a value-based oncology reimbursement model within the OCM requirements. “In particular, we develop a detailed tactical action plan with clear ownership within the practice…clear understanding of what the staffing needs are and where we need to hire, and where we can reuse or redeploy certain staff members within the organization,” she said. It is paramount to have a road map for the revenue cycle process with links to scheduling.
At The US Oncology Network, 12 practices involving 800 physicians and their care teams are participating in the OCM, and approximately 40,000 care episodes are initiated annually.
CMS will be auditing participating sites annually or semiannually, with a 2-week notice. “It’s imperative that every single one of those sites is performing and meeting all of the requirements. If they don’t see what they want to see, there’s recoupment…from Medicare,” she said.
The focus at The US Oncology Network has now shifted from participation to performance. The scope of transformation is centered on the OCM requirements, with emphasis on workflow and processes (Figure 1).
“We have a team of…mobilization leads that are supporting each one of our practices, and doing all the hand-holding, and helping them to put the right structure in place to be successful,” she said.
The coordination of care within the care team is essential, because the mix of players is large (ie, new patients, navigator, physicians, nurses, medical assistants, triage, and social workers). Physicians are asked to provide treatment plans to patients before the start of new chemotherapy or hormonal therapy, to assure documentation, to follow clinical care pathways whenever possible, to discuss advance care planning, to participate in team care activities (huddles), to interact with the navigator, and to make time slots for urgent visits (Figure 2).
“If patients call, we’ve got to make sure they can come in,” said Ms Verrilli. “They don’t always have to see a physician. Part of this program that we are carefully evaluating, and making changes in our staffing, is looking at that physician to advanced practitioner ratio to make sure we have enough staff to support individuals in these programs. Because we can’t do it with the staffing we have today. Every time a practice wants to hire a new physician, we are encouraging them to hire two advanced practitioners instead…depending on the practice,” she explained.
Care team measures of success include:
- Improved collaboration and coordination among the treating physicians (ie, medical oncology, radiation oncology, and surgical oncology)
- Huddle testimonials
- Staff and physician communication surveys
- Rework (eg, missed orders, redoing orders, order safety checks)
- Clinical trial screening and enrollment
- Staff utilization (eg, advanced nurse practitioners, registered nurses, social workers)
- Reduced staff turnover
- Less physician burnout (measure via survey).
The practice transformation is significant and the culture change required will take time to develop, Ms Verrilli emphasized.
“The notion of being more collaborative and getting the group to think more from a patient-centric perspective is really critical,” she said.