Top 3 Must Do's to Prepare for Managed Care in 2016

Diana Verrilli and Marcus Neubauer, MD
Published: Thursday, Mar 24, 2016
Diana Verrilli

Diana Verrilli

Last year we got a better glimpse of what managed care will look like in the future. Although there still are many unknowns, especially in light of this being an election year that will bring a new administration, it’s already very clear how the transition to value is affecting oncology practices.

For example, this trend continues to create a lot of anxiety for community oncologists. Many are concerned about payment changes, the loss of longstanding referral relationships as primary care physicians and other specialists align with specific networks, and whether oncologists can maintain practice autonomy. Given what we know today, practices should be sure to address the following items this year:

1. Be aware of and involved in what’s coming. Most oncologists chose their profession because they love caring for patients and find joy in conducting research to find new and better treatment options. Negotiating with payers and keeping abreast of payment changes are some of the “necessary evils” that many prefer to hand off to practice administrators. However, with so much at stake during this transition to managed care, oncologists must make it a priority to be aware of and involved in what’s coming.

While the future of payment methods for oncology care is still murky, there’s no doubt that our industry is rapidly shifting away from fee for service (FFS) to value-based care. There continues to be a lot of discussion about what constitutes value, and many organizations from payers to associations and physician networks are working to develop definitions and guidelines.

Payers now expect physicians to make treatment recommendations that are in the best all-around interest of the patient. That means choosing evidencebased therapies that deliver the best outcomes and being economically responsible. These have been the foundation of evidence-based pathways since they were first introduced by The US Oncology Network 10 years ago.

Value Pathways powered by NCCNTM are based on the National Comprehensive Cancer Network’s Clinical Practice Guidelines in Oncology® and The US Oncology Network’s Level I Pathways. They are up-to-date, peerreviewed, evidence-based practice algorithms for cancer treatment, and are designed to maximize survival, minimize toxicity, and provide cost-saving opportunities. They are brought to the point of care by Clear Value Plusâ„ , a regimen support tool that can interface with most electronic medical records (EMRs) and provides financial transparency and real-time reporting.

Oncologists should also keep a watchful eye on what The Centers for Medicare & Medicaid Services (CMS) is doing. Because a majority of cancer patients are 65 years or older and covered by Medicare, many practices receive 40% to 50% of their payment from Medicare.

CMS plans to launch its Oncology Care Model (OCM) on July 1. This episodebased payment model will manage chemotherapy treatment and the spectrum of care provided to beneficiaries receiving chemotherapy. Practices chosen to participate in the five-year pilot will receive financial support for transforming their practices, including monthly care management payments for participating Medicare FFS beneficiaries as well as retrospective performance-based payments. This compensation will be in addition to the services the physician provides and bills to Medicare.

Practices in this pilot are expected to rely on the most current medical evidence and share decision-making with patients about whether they should receive chemotherapy. The performance-based incentives are based on comprehensively and appropriately addressing the complex care needs of the beneficiary population receiving chemotherapy as well as furnishing services that specifically improve the patient experience or health outcomes.

Another organization with skin in the game is ASCO, as indicated by their development of a “value framework.” This framework compares one new agent in cancer treatment with the prevailing standard of care for a specific clinical cancer indication using data from a prospective randomized trial. Rather than scoring different drugs against each other, the value framework examines the clinical benefit and toxicity of an agent in order to generate a “net health benefit” score that is juxtaposed against the cost of treatment. It is designed to help evaluate the value of different cancer treatment options and facilitate discussion between physicians and patients when it comes to making decisions about cancer care.

2. Think holistically about your patients. Unplanned hospitalizations are very expensive, and physicians are being held accountable for their patients’ overall care. This elevates the need to be more aware of the treatment patients are receiving outside the oncology office.

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