navigating the new world of value based payment · 2020. 4. 16. · navigating the new world of...
TRANSCRIPT
Navigating the new world of value based payment
A community oncology business perspective
This presentation includes statements of personal opinion. Statements made throughout this presentation should not be assumed to reflect official positions or policies of Tennessee Oncology.
From the practice perspective:
Two decisions:1. MIPPS or APM?
2. Advanced APM or MIPPS APM?
MACRA
APM
scoring
MIPPS APM
Advanced APM
MIPPS
scoring
OCM risk upside only OCM downside & upside risk
What’s OCM?
The Oncology Care Model is CMS’s first widely accessible, voluntary, experimental payment model for medical oncology.
Upside only risk option = MIPPS APM
Two-sided risk option = Advanced APM
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Fundamental revenue and cost structure of OCM participation
1) Monthly Enhance Oncology Services (MEOS) payments• $156.80 per qualifying
Medicare beneficiary
2) Performance-based payments (PBPs)• Variable based on
performance
1) Program requirementsA. IOM Care PlanningB. Care NavigationC. Others (EBM tx, 24/7 access to
clinicians, use of EHRs, etc.)
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Revenue Costs
2) Total cost of care reduction
3) QM performance
MIPPS vs upside only OCM
MIPPS Scoring MIPPS APM Scoring
QM, ACI & IA reporting requirements
9 self reported measures + 3 claims based + ACI + IA (included in program requirements)
No guaranteed revenue increase $156.80 PBPM per attributed episode
Heavily codified in regulation Experimental payment model
Budget neutral payment adjustments No financial penalties
Excessive program requirements
MIPPS APM vs Advanced APM
APM (upside risk only OCM) AAPM (downside & upside risk)
Upside only20% stop loss
Cost of new drugs
156.80 PBPM 5% of all Part B prof. service fees
OCM & ACI QM reporting Reduced QM reporting burden
Why not A-APM?
Safest bet?
OCMUpside risk only
Overview of performance based payments (PBP)
% of risk adjusted quality measure points earned
Risk adjusted savings
(in excess of 7.2% hurdle retained by Medicare)
PBP Revenue
Major OCM-related initiatives*
1. Pathways program
2. Improved triage processes
3. Access to & utilization of palliative care
4. Improved care coordination
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* Initiatives that will reduce overall cost of care (gate-keeper for OCM performance based payments)
Source: Journal of Oncology Practice, November 2015.
How to approach practice transformation?
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Keys to success:
• “Box checking does not, by itself, improve care…it might be as simple as reforming telephone triage.”
• Successful practices have focused on:1. Pathways
2. Telephone triage
3. Same day appointments as problems arise
4. EOL discussions
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• “Data collection at baseline period showed 48% of symptom management calls being addressed within 2 hours. Staffing changes resulted in an improvement to 68%, and an additional improvement to 73% after implementation of the case management system.”
• “Data collection at baseline period showed that 35% of calls routed to the triage nurse were not appropriate calls for triage nursing. This improved to under 1% after implementation of the case management system.”
Results to date from triage process improvement initiative
Definition of care coordination
Triage protocols
Distress screening
New patient intake
Enhanced patient education
Access to palliative care
Closing the loop on symptomatic patients
Urgent care visits
Post discharge planning
Survivorship planning
Total Cost of Care Reduction
= Everything we do for patients outside of their office visit interactions with the provider
Success requires culture shift
1. Reduce hospitalization and ER visits
2. Patient-centered processes that improve patient satisfaction
3. Focus on overall health of the patient (including comorbidities, psychosocial problems)
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Source: Journal of Oncology Practice, November 2015.
We know the FFS world, how long will the transition to VBP take?
Clinicalpractice
Care coordination
Learning curve?
Information systems mgmt
Finance, operations & mgmt science
What to expect over the next few years?
“Medicare Accountable Care Organization Results For 2015: The Journey To Better Quality And Lower Costs Continues,” Health Affairs Blog, Sep. 2016.
