Best Practices in Oncology an Evolving Process
The Oncology Care Model (OCM) has been a topic for discussion at oncology conferences since June 2016. Ronald Barkley, MS, JD, President, Cancer Center Business Development Group, moderated a packed panel discussion titled “OCM Evolving Best Practices” at the 2017 Cancer Center Business Summit.
March marked a new milestone for practices that are participating in the OCM, because the Centers for Medicare & Medicaid Services (CMS) will release the first set of data spanning July through September 2016 on the actual beneficiaries assigned to the OCM program for each practice; these data will offer practices the first glimpse of how their OCM performance tracks against their potential for profit-sharing.
Value-Based Care Best Practices
Of the 196 practices that are participating in the OCM, 13 are part of the McKesson US Oncology Network; these practices comprise 800 physicians and approximately 17,000 OCM patients, stated Diana Verrilli, Senior Vice President, Payer and Practice Management Solutions, McKesson Specialty Health, Denver, CO.
In the first 6 months of enrolling in the OCM, practices in the US Oncology Network focused on integrated technology (using iKnowMed, decision-support systems, Clear Value Plus clinical pathways, and Practice Insight) and investing in care teams and enhanced services.
One of the biggest challenges in participating in the OCM is optimizing the claims data from CMS (ie, the 3-year historical snapshot received early in the program and the soon-to-be quarterly files received from active program data), said Ms Verrilli. Some of the actionable analyses the US Oncology Network is reviewing include peer benchmarking from the Center for Medicare & Medicaid Innovation (CMMI) and inside the network’s aggregated data, analyzing side-by-side performance by site and provider, and forecasting trend factors and total cost targets.
The CMMI historical snapshot claims data (from 2012 to 2015) yielded several baseline analyses, including hospitalizations, emergency department visits, hospice utilization, chemotherapy use in the past 14 days, deaths in the hospital paired with intensive care unit admissions, and utilization of positron emission tomography scan and growth factors.
US Oncology Network practices embrace the following value-based care best practices:
- Actionable analytics
- Navigation and team care
- Urgent care slots
- Patient treatment plans (standardized across the network)
- My choices, my wishes
- Core eligibility and enrollment principles.
“We think of this as an evolution; there is no way that we are going to be able to tackle all of this in the first 6 months. It is a significant practice change, preparing for value-based care,” said Ms Verrilli.
Some of the key challenges that the network practices have encountered while participating in the OCM program, she says, are challenges that non-OCM practices will likely also face as they transition to value-based care (driven by federal or private insurers), including:
- The pace of the program changes, and the volume of information that CMMI provides is useful but daunting and not what practices are used to dealing with
- Categorizing and identifying patient eligibility is especially a challenge for patients who are receiving oral treatment regimens
- Executing practice transformation, including the completion of the Institute of Medicine care plan
- CMMI has created very complex expectations and exclusions for care partner and pooling relationships, which are difficult to execute
- The OCM Data Registry submission process and timing of registry readiness is challenging, in addition to collecting the data required for submission.
“When we think of how to meet these challenges—using this information to allow our physicians to see how their choices compare [with] their peers, changing our physician behaviors, improving our pathways adherence rates, helping patients so that they don’t end up in the hospital or the ER [emergency room] when it could have been avoided, working on managed care planning….It is a lot for the practice to absorb,” said Ms Verrilli.
“Most of our practices are meeting as a team, once a week, to review and talk about OCM patients on a patient-by-patient basis, to discuss who is at risk and what those opportunities look like,” she added. She emphasized that this is an evolving process, and not an easy one for practices to adopt, but it also creates many opportunities for the future.
Tracking, Reporting, and Measuring
Flatiron Health is the parent company of OncoEMR, an oncology electronic medical records system that many community oncology practices use. Brenton Fargnoli, MD, Director, Product Marketing and Strategy, Flatiron Health, New York, NY, shared some of his company’s strategies for assisting OCM practices.
Flatiron Health serves 55 of the 196 OCM practices across 20 states. When Flatiron Health launched its program solutions in the summer, those at the company were amazed to receive proactive feedback from the participating practices in great volume. “We received over a year’s worth of feedback just this summer,” shared Dr Fargnoli.
“Technology is an important tool, but some of these problems are not technology problems,” he said. “Our users have formed a super group of users to discuss the differing practice circumstances, and how to leverage the common platform they use in varying ways. Practices that are not currently in the OCM program will eventually feel the need to address these same issues in any other value-based program.”
The care management of patients is one of the key challenges of the OCM program. Under the OCM, practices must identify and track patients, as well as inform them of their treatment care plans. Flatiron Health practices have identified more than 30,000 patients with OCM episodes, which will be difficult to track.
Program evaluation and reporting has emerged as another key challenge. Practices have learned that they cannot report and improve on quality and program standards if they cannot measure outcomes. With more than 500 different quality measures in several value-based programs, tracking and measuring numerators and denominators, and calculating the result of that measure, is a hurdle.
Revenue cycle management is the cornerstone of change under the OCM model. OCM practices need new tools to meet contracting challenges for the OCM program, because the tracking and billing of monthly payments for patients who qualify in defined episodes of care have taken more staff time and resources than the OCM practices had expected.
Flatiron Health has been working steadily with its 55 practices to execute solutions to meet the OCM challenges, and to prepare for the first deadline of quality measures reporting.
Financial Issues and the Risk of a 2-Sided Risk Model
A pioneer of value-based care programs, Barbara McAneny, MD, Chief Executive Officer, New Mexico Oncology Hematology Consultants, Albuquerque, reflected on the lessons that she and her colleagues learned during the early days of the COME HOME (an OCM) program and through the first 6 months of its launch.
Because of the OCM’s risk-based structure, it is possible that OCM practices will either succeed or fail, Dr McAneny advised. The $160 monthly payment is not sufficient to cover all the costs of managing and coordinating care, and hiring new staff for patient navigation without a clear understanding of how to effectively deploy these navigators is a challenge, she added.
The practices that are working collectively with Dr McAneny have implemented patient navigation among many people across the practice, based on their skill sets.
CMS requires that OCM practices develop and disseminate care plans to their patients, but these plans may not always be useful to the patient, she noted. Nonetheless, OCM practices are linking the provision of required information and documentation to patients as identifiable visits for specific, useful purposes to cover elements of the care plan and patient education.
Practices participating in the OCM must consider multiple questions, including, “Do we efficiently use the people that we hire to the top of their skill levels? Are we just documenting for the sake of documenting, or are we asking and answering questions that will yield actionable information or valuable and useful information to patients?” asked Dr McAneny.
Financial outcomes are going to be a serious concern for OCM practices and for practices that participate in other value-based programs that require them to accept a 2-sided risk, said Dr McAneny.
To hypothetically see how accepting a 2-sided risk arrangement against CMS target goals would look, Dr McAneny modeled a random mix of patients with episodes of care based on the experience her practice had under the COME HOME program.
She observed a significant number of scenarios in which her practice could have become obligated to pay millions of dollars to CMS under a 2-sided risk model. “This could be a practice-ending event,” she stated.
By 2018, practices that have not yet had a successful performance period will have to withdraw from the OCM program or enter into a 2-sided risk arrangement. By the middle of 2018, there could be many practices that no longer participate in the OCM, predicted Dr McAneny.
She has started to explore analytics to identify where new approaches may reduce the risks of a 2-sided model, including analytics by tumor type or by Hierarchical Condition Categories scores, in which more detailed coding of comorbidities will reflect the risk of patients in the CMS model.
Smart Practices: Leveraging Data Analytics
Ed Bassin, PhD, Chief Analytics Officer, Archway Health, Watertown, MA, spent 8 years working on bundled payment programs in various specialties, and the OCM program has validated the experience he has seen in every other case for value-based programs.
“In every other program, 2 things stand out as key success factors,” he said. These 2 things are:
- Keep it simple, stupid—when you start with a simple design, you allow people to innovate and experiment
- Don’t try to boil the ocean—CMS requires OCM practices to implement many changes at the same time, but when a program starts with requiring a few things at a time and then adds to them quarterly, it can effect real change. If the program tries to require all the changes at once, participants will end up complying in the most minimal way and fail.
“Everybody got into this program because they believe they can save money, but the challenge is finding the data analytics to help to identify opportunities and to prove the results,” he said. Archway Health is working with its client practices to build comparisons and to analyze variability of treating physicians and hospitals to look for significant improvements and changes.
“There is waste in the healthcare system, and there are clear opportunities to do things in more efficient ways. Smart doctors and smart practices can be incredible innovators,” Dr Bassin said.
He conveyed his concern about the 2-sided risk model for oncology practices, saying, “No one in their right mind would ever seek to start an insurance company with 400 enrollees. That is what a practice is being asked to do under a 2-sided risk.”
Challenges and Opportunities
The panelists saw great opportunity for OCM practices to make a significant difference in the quality and costs of care over time. However, they expressed significant concerns about the expectations of the OCM as it is currently modeled, especially the 2-sided risk arrangement.
Nonetheless, the panelists expressed hope that improved analytics on the part of the providers will yield opportunities for honest conversations with CMS that can reshape the OCM into a more achievable success story.