Oncology Through a Fractured Looking Glass: How to Compete?

Dawn Holcombe, MBA, FACMPE, ACHE

November 2013, Vol 3, No 7 - From the Editor


Oncology is being actively managed by many entities, and in quite different ways. How will oncology practices and practice managers adapt, compete, and succeed in this fractured world? The first step is to look at the specialty through these many prisms and understand what gaps you might be able to fill.

Category 1: Patients

Most patients will seek hope and care. They may be willing to be actively engaged, or they may be completely overwhelmed and unfocused. Someone will provide direction. However, that direction could potentially come from outside of the traditional physician/patient relationship, and that direction may or may not be communicated to the physician. Not only that, the outside direction could possibly conflict with the medical plan. For example, some direction may be financial, because benefit design and formularies for insurance can and do put parameters on patient choice. Going forward, patient-reported outcomes will increasingly become part of the evidence for value-based decision-making.

Oncology Practice Manager Plan
Review your market. Look for trends in patient benefit structures related to shifting care choices. Are you on the “preferred physician” lists? How do copayments at your site of care compare with those at others? Are there case managers or navigators touching the patients? Can you talk to those managers and navigators to build relationships and closer communication for the good of your patients and to maintain referrals? Assess how you currently measure patient-reported outcomes. What gaps exist? What results can you integrate in a value-based discussion?

Category 2: Health Systems

Health systems focus on the community and manage single components much like chess pieces. Oncology is just one specialty among many, but one that affects many ancillary elements of the health system, so it is perfectly logical that health systems would seek to integrate oncology back into the fold. Yes, there are drivers like 340B, but the greater drivers are the need for health systems taking on accountable care and eventual risk—which will require control. Health systems are now at financial risk for several health measures, including readmissions, and are likely to increasingly engage case managers and patient navigators. Health systems are likely to secure as much of the primary care market as possible, and in doing so, control oncology referral patterns. Health systems may not understand all of the issues related to oncology, but they will be more likely to look at the diversity of upstream and downstream patient connections outside of the oncology medical practice. This broad view of the patient will align closely with the goals of payers and the Centers for Medicare & Medicaid Services, and it potentially could conflict with—or benefit from—the oncology medical home concept.

Health systems can achieve quality ratings and accreditations that individual practices cannot. Their infrastructure could embrace consistency of process and information sharing/reporting across large databases in a way that individual practices cannot. Conversely, a large infrastructure could be a burden, but the expectations for monitoring, reporting, variation reduction, and patient accountability across all care may be perceived as easier for a health system to manage than an individual practice.

Oncology Practice Manager Plan
Watch health system activity in your market, even those with whom you are not affiliated. Seemingly overnight, new affiliations or mergers can happen and, if your primary systems become the underdog, referral patterns could dry up in favor of the dominant system. Engage the C-suite leaders regularly. Become part of their plan and infrastructure for addressing oncology management issues. Remember, practices do not need to be employed by a health system to engage with a health system. However, developing the needed close infrastructure and informationsharing will require trust and regular communication. Some health systems will find that collaboration with local individual practices is essential for meeting the new requirements for maintaining Commission on Cancer accreditation, and savvy practices are leveraging inclusion in that process. What accountable care initiatives are progressing in your market? Have you engaged those entities in discussions and planning yet?

What quality accreditation op­tions are available to your group? Are there potential partners available? How does your group compare in terms of quality assessment and reporting with area competitors? Do you track competitor reporting yet?

Category 3: Payers

There is no one description for oncology-related activity that fits all payers, except that oncology is a top concern for them. Some payers are exploring with pilots in some markets and some practices. These pilots include bundled payments, pay-for-performance, partial or full risk arrangements, and many variations of shared savings. After several years of pilots, there is still no single solution that has emerged as universal and scalable. Some payers will continue to explore innovative solutions. Others are increasingly looking at internal data collection from prior authorization programs to build their own profile of care and treatments—to be used later as support for narrowing variation through their analysis of evidence-based care. Still others are using third-party vendors to apply oncology management solutions (albeit still focused primarily on drug choices rather than full-care perspectives), so that all oncology care can be run through one consistent filter, regardless of the site of care. Other payers have not yet made decisions beyond drug approvals and management, but they are seeking other potential solutions.

Oncology Practice Manager Plan
Focus internally and externally at the same time. Engage the medical director of each of your top 6 health plans—partner them with one of your physicians. Touch base regularly to understand their current concerns, and to let them know that you are willing to work with them. When I talk with payer medical directors, I never cease to be amazed at how many say they have never been personally approached by key oncology providers to talk about these issues.

Understand and track what data are being collected by which plans through prior authorization and medical necessity challenges. Pursue and implement internal improvements and oncology medical home precepts, not with the expectation that there will be increased revenue opportunities if you do so, but with the expectation that such improvements will allow for enhanced patient care to make the practice an attractive partner in oncology management or accountable care projects. Additionally, streamlining processes and reducing variation will prepare the group for ultimate bundled-payment arrangements that will come from federal, state, and private payers over the next few years.

Category 4: Federal and State Insurances

Medicare, Medicare Advantage, and the myriad of new federal and state insurance exchanges and managed Medicaid insurance plans will all seek cost reductions. We are now seeing Medicare Advantage plans dropping practices and payment structures of 100% of Medicare in favor of those who will accept percentages less than Medicare. The growing challenges around the insurance exchange programs have not yet begun to sort out in terms of provider networks and payment rates for those provider networks, or in terms of actual care coverage, especially for oncology. Practices are likely to see challenges even from networks where primary care physicians are placed at risk for total costs of care, including oncology costs.

Oncology Practice Manager Plan
This category may represent the greatest financial risk to oncology practices over the next 24 months. Carefully track contracts and comparative payment rates across these types of insurance arrangements. Actively engage in dialogue with primary care referrers to assess what changes may be looming for your referral patterns and your own potential contracting issues if those primary care providers start to assume risk. Investigate your groups who are standing against competition in the market regarding utilization, average costs of care, patient satisfaction, admissions, marketing, quality reporting, etc. Watch state exchanges carefully and look at preferred insurance networks. Are you a part of those networks? Have you received contracts and are the payment terms and other limitations/parameters acceptable?

In addition to these general perspectives, there are many employers starting to contract individually with oncology providers or external vendors to manage oncology. Pharmacy benefit managers and specialty pharmacies are actively developing both medical and specialty pharmacy oncology management strategies.

Conclusion

The watch word as we end this chaotic year is: Look.

Look at how your market is changing; look at how the public and private exchanges will modify your markets in 2014. Look at who is doing what and who is working with whom locally. Look at how you are being perceived and how you stack up against your current and future competitive and collaborative relationships.

We will emerge after the next 2 years looking quite different than we do today—and that will be a reflection of the varied perspectives on oncology that are present now. If we recognize the way oncology management is being viewed and potentially fractured, we can design a workable solution to get to the other side whole and be able to continue to serve our patients.

About the Author

Dawn Holcombe is the president of DGH Consulting in South Windsor, Connecticut, and the Editor-in-Chief of Oncology Practice Management. She can be reached at 860-305-4510 or by e-mailing dawnho@aol.com. Visit her website at www.dghconsulting.net.