New Models May Bridge the Payment Gap

Andrew Smith
Published: Saturday, Jan 28, 2017
Barry Russo

Barry Russo

The Center for Cancer and Blood Disorders (CCBD) believes that its acupuncturist, dietitian, psychotherapist, and other ancillary service providers extend patient's lives and decrease total treatment costs by reducing hospital visits. In the past, payers did not agree and would not pay for such services, which is one reason why partners at the practice are excited about the ongoing transition from fee-for-service payments to fee-for-outcome payments.

“If payment models truly allow practitioners to share in cost savings and to profit from improved outcomes, then it will make sense for us, financially speaking to provide all services that make sense medically speaking for our patients. We will be able to make our best medical judgment, but we will be risking our own money on that judgement, which is fair,” said Barry Russo, who manages CCBD’s 185 employees at nine offices across the Dallas-Fort Worth metropolitan area.

“The payment structure isn’t there with any of our payers yet. We’re still in very early days of creating models that evaluate our impact on costs and outcomes, but payment models are certainly moving in a direction that rewards practices for efficiently providing superior care, which is good news for practices that do, in fact, efficiently provide superior care,” Russo said.

Payment models have already shifted enough that CCBD has reaped financial benefits from its decision to implement the oncology medical home (OMH) practice model. That model, along with several other closely related patient care strategies, is designed to simultaneously slash total treatment costs and improve patient outcomes, largely by identifying and addressing problems before they get bad enough to send patients to the hospital (Table).

A cornerstone of these models is centralized telephone triage lines that operate 24-7 to answer patients’ questions as soon as possible and arrange immediate appointments for those who need them. These speedy appointments typically require longer operating hours, such as on the weekend, or increased staffing. The new models also emphasize both greatly improved communication with patients and increased reliance on standards of care and correspondingly less reliance on physician discretion.

The transition took thousands of staff hours for CCBD. Even a seemingly simple step, like replacing individual telephone numbers at offices with a single point of patient contact, proved to be a major undertaking. Worse, the practice needed to document that it was undertaking every step correctly if it wanted to be certified as an OMH or meet the standards for programs such as ASCO’s Quality Oncology Practice Initiative. Still, the extra work was less of a challenge than the radical changes to patient–caregiver interaction.

Under the old system, patients with questions called their individual treatment center and often spoke directly to their usual nurse or their doctor. With the new system, calls go to a single triage operation staffed by nurses who never see patients in person. Several other aspects of the new model—such as the longer operating hours—tend to increase the number of people with whom CCBD patients interact at the practice and tend to distribute decision-making power from each patient’s doctor to a number of CCBD team members.

“It’s a mistake to underestimate how big a change this model represents. It’s not just a huge amount of paperwork and computer updates in the back office. It’s a major change in workflow for every physician, every nurse, and everyone else,” said Ray D. Page, DO, PhD, the practice’s managing partner. “You need universal buy-in to make it work well, and I can fully understand why many practices wouldn’t want to do it. The trouble is, practices that don’t make transformational changes are not going to be able to survive under new payment models.”

Page believes practices that want to make the full transition to the OMH model need to negotiate new compensation models with at least some of their payers before they undergo a comprehensive transition. Several components of the model—keeping open appointments for emergencies, having more patient interactions with the care team, and actively checking up on patients who are acutely ill—undoubtedly increase costs. Practices that implement these components without negotiating to share in any possible hospital savings put themselves at risk of heavy financial loss.




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