Seeking the Win/Win/Win for Patients, Practices, Payers
At this point in the move from fee-for-service to value-based reimbursement, everyone in healthcare is familiar with the triple aim of improving the patient care experience, improving the health of populations and reducing the per capita cost of care delivery. Yet, buying into the principles and putting them into practical application continue to be challenging for many providers.
Kashyan Patel, MD
To address the disconnect and discuss the latest trends in delivering the most effective, cost efficient, patient-centered care, the American Journal of Managed Care® (AJMC) and its Institute for Value-Based Medicine® host regional and national conferences to share insights on payment reform and patient care initiatives and at the intersection clinical, operational and financial performance.
The southeastern regional VB-Onc™ meeting was held in Nashville last month, and Philadelphia hosted Patient-Centered Oncology Care 2019 on Nov. 8. Nashville co-chair Stephen Schleicher, MD, MBA, a medical oncologist with Tennessee Oncology, and Philadelphia co-chair Kashyap Patel, MD, a partner with Carolina Blood & Cancer Care Associates and associate-editor-in-chief of AJMC, recently made time to update Medical News on the progress and challenges to delivering patient-focused, value-based care to cancer patients.
"2016 launched the first cancer-specific, value-based payment model called the Oncology Care Model," Schleicher said of the national CMS Innovation Center pilot. "There are about 185 practices involved, and the vast majority are community-based practices," he continued, adding a handful of academic medical centers, including University of Alabama Birmingham and Vanderbilt University Medical Center in the Southeast, are also involved.
While the goal of the Oncology Care Model (OCM) is to save dollars while providing high-quality, coordinated care, Schleicher said there is an absolute 'patients first' mentality. With many novel oncologic drugs costing thousands of dollars, Schleicher stressed OCM doesn't look to restrict effective treatment but rather to find savings elsewhere.
"First, when there's a drug that comes out that is FDA approved that we know has beneficial properties for a patient - right patient, right time - we'll do everything to ensure that drug is administered," he said. "Where two drugs with equal efficacy are available where there is a big cost difference, the goal is to use the one that's less expensive as long as there are no additional side effects."
Schleicher continued, "The challenge is a lot of payers think there are many more times in a patient's treatment when there are two options that are of equal efficacy ... but that is the exception rather than the rule."
Instead, the focus is on care coordination to try to keep patients comfortable and progressing in their treatment plan in the home and clinic rather than higher acuity settings.
"It's better to keep the patient out of the hospital, and it's higher value care to do that," Schleicher pointed out. "It's best for the patient and for society."
He added deploying palliative care with a focus on symptom control, using analytics to parse reported patient outcomes and improving communication and care coordination to holistically manage patients are a few of the innovative tools being used to bend the cost curve.
The recent regional VB-Onc conference drew attendees from the back office to the front lines of care to bring everyone up to speed on where things stand with OCM and discuss the larger challenges to succeed in a value-based delivery model.
"The Oncology Care Model is a five-year pilot, so it ends in 2021," Schleicher noted. However, he speculated CMS would either extend the model or move to something more substantial like a bundle payment. "I don't see anyone in the government or commercial payers backing away from value-based care anytime soon." He added, "Patients are already overwhelmed with their diagnosis and treatment. Anything we can do to limit unnecessary financial strains on patients I think we all agree is important."
For practices that haven't yet dipped their toes into the value-based waters, Schleicher said it might not be an optional course in the future. While OCM was a voluntary program, he pointed out the new radiation oncology bundle is mandatory.
The problem for many smaller practices is a lack of resources and infrastructure to effectively participate in an analytics-intense model. "We're not good at understanding our costs, and that's the first step in value-based care," he noted. "It really takes analytical tools to understand how you are doing among your peers and your colleagues nationally."
In addition to understanding costs, he said measuring how you are doing on pathway adherence, understanding the patient experience, and taking a hard look at dispensing futile care at the end-of-life are all important aspects of value-based care. Schleicher, who also serves as chair of the quality and value committee for OneOncology said the impetus behind creating a national network for community-based oncology practices was to leverage economies of scale, intellect and expert knowledge to help practices prosper in this new model while maintaining their independence as a private practice.
"Unfortunately, practices that are on their own might not have the expertise or resources to adapt to value-based care. For small practices, that's where larger, innovative groups like OneOncology can add tremendous value," Schleicher said. "We're all in this together for our patients ... we're not competitors in this space."
The Philadelphia conference turned the focus to the patient in the middle of the Oncology Care Model. As an OCM site, Patel has seen how putting the model into action is a win/win for patients and providers at Carolina Blood & Cancer Care Associates. "Once we were designated by Medicare as an Oncology Care Model participant, we got additional funding which allowed extra investment in care coordination and expanded access," he noted.
Not only did the practice purchase a new CT scan and start offering clinical trials, but they also invested in ancillary services in the clinic including in-house spiritual and hospice counseling, nutritional services and yoga sessions.
Patel said, "We keep two open slots at the clinic every day so if a patient needs to be seen, they don't have to wait two to three weeks for an appointment. We see patients as they need to be seen." As a result, he continued, "We're able to reduce the likelihood of a patient going to the ER after hours, which works best for the patient ... and for us.
"The patient doesn't have to waste seven to eight hours of their life (in the ER), and I don't have to round early the next morning," Patel added with a chuckle. "Our patient satisfaction rate has gone up to the top tier in the 80-90 percentile."
While the physicians love not going to the hospital as much, the change runs much deeper than that. "It's a win/win for everyone," Patel explained. "We feel by providing patient-centered care, it has allowed us to fulfill our purpose as a doctor. At the end of the day, we all have a purpose. I see myself as not just a dispenser of medicine but as a healer."
By taking the holistic view, he said clinicians now really see patients as human beings with aspirations and expectations. "We broke all the silos. Instead of seeing the compartments, we now see the whole patient. We've become part of the patient's microecosystem."
In addition to the increased satisfaction levels, Patel said the feedback the practice receives every six months from CMS shows a third win ... lowered cost. "We reduced our hospitalizations by about 30 percent and reduced the total cost of care by about 17 percent," he said. "About 50 cents on every dollar in oncology is spent in hospital-related services, but if you reduce the number of patients going to the hospital, it will significantly bend the cost curve," he concluded.