How to Avoid Being Blindsided in 2020

Dawn Holcombe, MBA, FACMPE, ACHE
Editor-in-Chief
President, DGH Consulting, South Windsor, CT

Still waters run deep. While cancer centers and practices continue to navigate the highly visible challenges of operations, reimbursement, and competition, as well as Medicare and private payer relationships, other potential hazards may be lurking just out of sight. This article discusses 3 areas where activity in your local market could suddenly surface and completely change the environment in which you provide care.

State Payment Reform

Individual states have been quietly developing value-based care initiatives, frequently under the radar of oncology specialty providers. From Washington to Connecticut, these initiatives are designed to change the competitive positioning of healthcare providers in individual states (often initially for the population of insured state employees). In a 5-year period (2014-2019), there was a seven-fold increase in the number of states and territories implementing value-based reimbursement programs. Currently, 48 states have been identified across the country, if you count the District of Columbia and Puerto Rico. In addition, 23 states have established value-based payment target mandates that payers and providers have agreed to achieve.1 Many of these are focused on primary care, but a growing number are targeting specialty care, including oncology.

Overall, 3 states stand out for their broad range of initiatives, their embrace of payment models that involve shared risk, and their willingness to test innovative strategies.

  • New York
    Through its State Innovation Models grant and demonstration waiver from the Centers for Medicare & Medicaid Services, this state has tested a Medicaid pay-for-performance payment model and risk-sharing arrangements with managed care organizations, in addition to various value-­based payment pilots focusing on maternity care, HIV/AIDS, and integrated primary care.
  • Pennsylvania
    Since 2013, this state has included complementary strategies for achieving reform, such as multipayer Episodes of Care payments for acute care; global payments for enhanced primary care through patient-centered medical homes; and a global budget for rural hospitals. This state also required managed care organizations to shift 30% of their payments into Alternative Payment Models by 2019.
  • Vermont
    This state began its transition efforts in 2011, when it initiated a patient-centered medical home strategy. Since then, it has deployed several value-based payment strategies, including an all-payer Accountable Care Organization model, Episodes of Care for the Medicaid population, and Health Homes.1

To learn more, I recommend checking out the following sample links to state initiatives: from Washington (Click here) and from Connecticut (Click here and Click here).

Preparation Tip

Identify and track initiatives that may be happening in your own backyard. Google terms such as “your state,” “value-based payment,” and “Episodes of Care.” Connecticut is moving on a rapid timeline for early 2020 to create a competitive ranking and payment system for all providers based on Episodes of Care. The intent is for every provider to be placed in 1 of 3 “quality” tiers, with the best payment terms for the top tier, with the ultimate goal of saving at least 10% on healthcare costs for state employees. It is interesting to note that very few of the providers in Connecticut—even hospitals—seem to be aware of the imminent changes, and how they will be judged and placed.

Employer Initiatives in Payment Reform

Employers have been joining forces under a variety of groups and titles, on a local, regional, and national basis, to focus more intently on their roles as purchasers of healthcare. Two of the more prominent and active groups on a national level are the National Business Group on Health and the National Alliance of Healthcare Purchaser Coalitions. Examples of local or regional groups include the Alabama Employer Health Consortium, the Connecticut Business Group on Health, the Florida Alliance for Healthcare Value, and the New Hampshire Purchasers Group on Health.

Some of these business-based groups have already initiated programs and are researching their costs of oncology care and potential alliances with providers. Others may be interested but have not yet decided how to begin. Some groups are setting regional prices and terms for potential participating providers that are different (in both positive and negative ways) than the traditional market payer contracts.

Preparation Tip

Subscribe to your local business journal or newspaper. Join local healthcare-related business coalitions or groups. It may require some digging to find the name for these activities, but try various Google searches using your local area combined with terms such as “business” or “health.” Chances are good that you will find local conferences or meetings related to cancer care and management that have occurred in your market. Find out who the speakers were and consider how the topics may apply and be used in your own discussions (internally and externally). If the discussions have already started in your markets or state, figure out a way to sit at the table, volunteer, join, and become part of the conversation.

Competitors for Infusion Drugs

Regardless of what happens with the “official” or “unofficial” rollout of pharmacy standards such as the US Pharmacopeia (USP) chapters on Pharmaceutical Compounding – Sterile Preparations (USP <797>) and Hazardous Drugs – Handling in Healthcare Settings (USP <800>), we will see individuals and/or organizations hold them up as a standard and comparator for physician practices and cancer centers in 2020. It may be a local hospital or academic center, a specialty pharmacy that wants to take over the market for infusion mixing by white bagging, or a staff whistleblower who is convinced they are in jeopardy. The frequency and speed with which this happens may vary across different states and geographies. Unfortunately, nurses and pharmacy staff are already being exposed to articles by USP <800> proponents, asserting that these changes are necessary to protect the health and safety of anyone in a facility where hazardous drugs are utilized, which may instigate whistleblower situations if those changes are not made. For example, one of the authors of the article “Safe Handling of Hazardous Drugs: Reviewing Standards for Worker Protection,” which was recently published in Pharmacy Practice News,2 is Martha Polovich, PhD, RN, AOCN, who also happens to have served in the past as a member of the Expert Panel on Hazardous Drugs for the United States Pharmacopeial Convention.3

Preparation Tip

Anyone who believes the local Pharmacy Board Inspectors are not going to inspect them, or who thinks that the State Board of Pharmacy or legislature will choose to not apply USP <797> or USP <800> to medical practices or cancer centers may be blindsided from another direction. If outside forces have educated staff members in the belief that USP <800> is essential to protect the health of workers exposed to hazardous drugs, private litigation is highly likely; we have seen this happen in some states.

Some national clinical trial networks are now requiring that private practices that use their clinical trials prepare their drugs in facilities that are USP <797> compliant. In addition, accreditation entities, such as the American College of Surgeons Commission on Cancer, cite compliance with USP chapters in their requirements. Hospital networks, managed care networks, and specialty pharmacies have also identified compliance with USP chapters as one of their criteria for network inclusion.

Practices should understand the terms of the USP chapters and consider how they may achieve compliance, as a competitive and proactive position, regardless of the legislative or regulatory environment in their local market regarding these chapters.

Conclusion

At any point after December 1, 2019, cancer centers and oncology practices could see one or more of the issues discussed in this article surface in their markets. Taking proactive steps to prepare for and deflect challenges that could threaten their ability to care for patients and maintain their operational stability will be critical for strategic leadership. By being aware of the risks and taking the necessary steps to prepare, the impact of the inevitable can be mitigated.


References

  1. Change Healthcare. Value-based care in America: state-by-state. April 25, 2019. www.pcpcc.org/sites/default/files/resources/%7Ba7b8bcb8-0b4c-­4c46-b453-2fc58cefb9ba%7D_Change_Healthcare_Value-Based_Care_in_America_State-by-State_Report.pdf. Accessed November 11, 2019.
  2. Power LA, Polovich M. Safe handling of hazardous drugs: reviewing standards for worker protection. January 11, 2018. www.pharmacypracticenews.com/Review-Articles/Article/03-18/Safe-Handling-of-Hazardous-Drugs-/46654. Accessed November 11, 2019.
  3. Ensuring Readiness for USP Chapter <800> on Handling Hazardous Drugs: Assessment, Planning, and Implementation. Presented as a Midday Symposium and Live Webinar at the 51st ASHP Midyear Clinical Meeting and Exhibition; December 6, 2016; Las Vegas, NV. https://ashpadvantagemedia.com/800/files/usp800-handout.pdf.

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