CMS Claims Data Provide Glimpse of True Cost Picture

Meir Rinde
Published: Friday, Oct 27, 2017
Sarah Cevallos
Sarah Cevallos
Since March, practices in the CMS Oncology Care Model (OCM) have been receiving giant data dumps every 3 months containing all their patients’ recent Medicare claims. The spreadsheets cover every provider the patients have visited during their cancer treatment. As the OCM practices work to reduce Medicare’s overall spending on those patients and to earn shared savings payments, the data are providing them with an unprecedented full picture of the extent and cost of care.

“When it first came out, the reaction was, ‘Wow,’” said Robert “Bo” Gamble, director of strategic practice initiatives at the Community Oncology Alliance (COA). “Practices have never known, and now they do. Now they can respond to it.” (Figures 1, 2)


Figure 1. Practices Have Used CMS Data to Calculate Total Costs of Care

CMS Data to Calculate Total Costs of Care

Figure 2. Oncology Care Model Practices Track Inpatient Admission Rates by Physician

Oncology Care Model Practices
For many practices, the data feed confirmed that steps they had already taken, such as encouraging patients to call in when they feel nauseated or dehydrated, had already reduced emergency department (ED) visits and hospitalizations. In some places, managers quickly noticed high costs or overuse of services at outside providers, pointing them toward ways to further reduce spending.

Northwest Medical Specialties, a practice in Tacoma, Washington, with 9 oncologists and 6 other physicians, studied the data and was pleased to learn it had reduced ED admissions by 25% and hospital readmissions by 15% compared with an earlier, baseline period, said COO Jeff Hunnicutt. He said it was also “really exciting” to link the Medicare claims to detailed clinical data that the practice has been collecting in its electronic medical record. That allowed comparisons of spending on different disease stages and insights into the cost impact of psychosocial factors such as living alone or living with a disability.

Another feature is greater transparency on how other providers operate and how much they charge Medicare for services. “It just kind of confirms the suspicions you’ve always had, that hospitals are ridiculously more expensive than community oncology. You see things like a flow cytometry test that costs $1000 in our clinic. If they do it in a hospital, it’s $4800 for the exact same process. There are hundreds of things like that,” Hunnicutt said.

The staff noticed one local hospital has a much higher admission rate than others and reached out to ask why. “We came to find out it was an internal directive that oncology patients who came into the ED were almost exclusively admitted to the hospital, which we look at as just being shocking. That hospital is doing something we would not think is morally in the best interests of the patient,” Hunnicutt said. The hospital’s reasons may include the resulting profit as well as fears about managing oncology in the ED, he said. Northwest Medical voiced concerns but is not discouraging patients from using the hospital, because it is convenient for them and is an important source of referrals for the practice, Hunnicutt said.

Another practice that gained useful data on partner providers is Florida Cancer Specialists (FCS), one of the largest OCM participants, with more than 200 physicians at close to 100 locations. Chief revenue cycle officer Sarah Cevallos said the data feed validated the practice’s understanding of differences in hospital costs among regions and allowed the organization to “slice and dice” the numbers to identify which specific diagnosis, disease, therapy, office location, or other variable represented a challenge or opportunity.

For example, the data seemed to indicate that some FCS clinics were making unusually high rates of referrals to hospice, which was very concerning, Cevallos said. Further investigation of one site revealed that patients were frequently referred but not necessarily admitted to a particular hospice. It turned out the hospice provider was undergoing an ownership change, and its relationship with the clinic was in flux.

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