If you are like me, you are checking your email inbox every few minutes to see if the Centers for Medicare & Medicaid Innovation (CMMI) has announced its proposal for a new way to pay for cancer care provided to patients with Medicare.
While we are waiting, the Centers for Medicare & Medicaid Services (CMS) gave us some big news about how quickly it intends to move to value-based payment. By the end of 2018--just three years from now--it plans to have 50 percent of its payments to physicians and hospitals be based on the quality and cost of care they provide.
I had the chance to speak with Lindsay Conway and Rob Lazerow from The Advisory Board Company to get their take on what this all means for oncologists. The Advisory Board Company is a research, consulting, and technology company that works with about 3,800 hospitals, health systems, employed medical groups, and independent physician practices.
Conway heads the company’s Oncology Roundtable, a membership program for cancer care administrators, most of whom work in hospital-based cancer programs.
Lazerow leads the Health Care Advisory Board, working with senior health system executives and overseeing research about new payment models.
Here’s a transcript of our conversation – you can also listen to a podcast of the full conversation in the iPad edition of OT’s March 10 issue.
CMS said its target is to have 30% of Medicare payments tied to quality or value through alternative payment models such as accountable care organizations (ACOs) and bundled-payment arrangements by the end of 2016, and 50% of payments by the end of 2018. To give some context, about 20% of Medicare payments in 2014 were in these alternative payment models. Do these targets seem like steady, incremental growth--about what you were expecting--or do these seem like aggressive targets to you?
Rob Lazerow: “I think this is a big announcement. If we think about the experience with payment reform that we’ve had for the past few years, it started out with a bunch of demonstration projects. We had the Acute Care Episode demonstration for bundled payments. There was an ACO demonstration project too. And then those became some of the voluntary programs that were included in the Affordable Care Act. So, think of the Pioneer ACO model, the Medicare Shared Savings Program, and now the Bundled Payments for Care Improvement initiative. They are interesting programs with, putting them all together, thousands of organizations participating in different ways.
“But they have all been voluntary. And I think that the hospital and health system leaders -- at least the ones that I work with -- have been looking for clarity around the direction that CMS is headed with respect to risk-based payment. I think last week’s announcement really removed any lingering uncertainty about the transition to risk-based or value-based payment over time. CMS gave the clarity the providers needed to invest in the infrastructure, the care models, the personnel, the culture change, that’s needed to thrive under these new payment methodologies.
“Now, the numbers themselves are ambitious. To say that 50 percent of Medicare payment is going to flow through these alternative payment models – ACOs or bundled payments – that’s a pretty big transition from where the industry is right now. I think it’s safe to say that these are some aggressive, ambitious targets. But the signal value for providers is exactly what they’ve needed to get out of what I like to think of as one foot in two worlds, where they have some experimentation with risk-based payment, and the rest of their business in fee-for-service. Now they have a clear sign to move ahead with the transition to value-based payment.”
The day after CMS’ announcement, several of the nation’s largest health systems and insurers said they have formed the Health Care Transformation Task Force with the goal of shifting 75% of their business to ACO, bundled payment, and other new types of contracts by 2020. Thinking about this in conjunction with the CMS announcement, what are the implications for physician practices in the next five years?
Lazerow: ”I think there are three big implications: First, just like I mentioned with hospitals and health systems, physicians have been waiting for the clarity around transforming to new payment models. They feel those conflicting incentives, and it’s challenging for physicians to think about potentially practicing differently under different payment models. That’s not how they think, that’s not how they live and breathe. So, first of all, this gives physician that same clarity.
“Second, the announcement from the Healthcare Transformation Task Force reiterates the fact that payment transformation needs to be a multi-payer effort. Providers, whether they are organizations or physicians, can’t live with different business models and different incentives. They need to be transforming not just their Medicare book of business, but also their commercial and Medicaid and other state-based program business. And this announcement from the Healthcare Transformation Task Force reiterates that this isn’t just Medicare moving this direction, but it’s also commercial payers and employers, as well.
“Finally, it’s the idea that when you put together both Medicare and public payers, there has to be a sizable portion of overall business at risk in order to really meet a tipping point or a critical mass of business under value-based purchasing. The organizations that are part of this task force have experience with risk-based payment. And what they’re saying is that this is not experimentation. It is not a pilot. This is their commitment to make it their dominant business model. These organizations that already have a foot in that direction, and in some cases, much of their business in that direction, but they are really doubling down on aggressively transforming and accelerating the transformation to a new value-based business model.”
CMS is planning to test new payment models for specialty care, starting with oncology care. When do you expect the details of the oncology payment model to be released? And what kind of payment model do you expect CMS to propose?
Lindsay Conway: “Of course, things are always in flux. The last I heard, CMMI was hoping to release a detailed proposal about the Oncology Care Model [scroll to “Government Plan” heading] sometime in February, actually. So we are eagerly awaiting the release of that proposal.
“In the meantime, we do have a design paper that CCMI released back in August, which gives at least a high-level outline for what they are thinking here. It’s very interesting, because when you look at how they have structured the finances, there is really only upside financial opportunity for oncologists. The way it works is: it is traditional Medicare fee-for-service payments and, on top of that, oncologists would also be earning a per-beneficiary per-month payment. In addition, they would have the opportunity to earn a shared savings bonus if they hit certain cost and quality goals.
“So from a financial standpoint, it’s great for oncologists (scroll to page 4). There are some catches, though: One is that the barriers to entry are quite high (scroll to the bottom of page 1). CMMI is requiring that oncologists provide what they call a list of enhanced patient services. It’s quite a lengthy list of services--for example, providing 24/7 access to a clinician who can access their medical records; providing navigation services; and providing survivorship care planning.
“Of course, everyone knows that these are very expensive services to provide, so that might be out of reach for some oncology practices.
“The other catch is that CMMI is also proposing significant quality reporting requirements. Again, they have quite a lengthy list of metrics that they hope to include in the program, many of which require manual data abstraction. So that’s another significant barrier to entry.
“Obviously, there’s still a lot of details that we are hoping to see in the proposal. I think one of the most important will be hearing what the per-beneficiary per-month payment is. A lot of the reaction to this model will hinge on whether or not that payment is sufficient to cover the additional costs that are essentially required for participating.”
[Note: Check out the American Society of Clinical Oncology’s thoughts about the Oncology Care Model.]
Lazerow: “You hit on two of the attributes that we have seen more broadly as part of the payment transformation conversation. First is the strong inclusion of quality metrics. So, if we think about the 33 quality metrics in the Medicare Shared Savings Program, for example. CMS is being clear that they will not reward organizations for generating savings while sacrificing quality. That is a strong signal that we will see in any of these payment models.
“Second is the evolution that starts with upside bonus opportunity, and then may evolve to both upside bonuses and downside penalties as the new payment models evolve. When I think about some of the conversation underway right now as CMS put out its proposed modifications to the Medicare Shared Savings Program, a big question there was about how do you get providers to voluntarily take on both the upside and downside risk rather than just stay in the bonus-only world. So, I think that will be something to watch on the horizon as the oncology bundles and programs continue to roll out.”
Conway: “And that really gets at the central challenge associated with developing risk-based contracts or value-driven contracts in oncology: We still lack a broad set of consensus-based quality measures for cancer care. If you want to pay for value, that makes it really, really hard, because we can’t actually define what that is.
“That said, I do think that CMMI’s design paper on the Oncology Care Model is extremely interesting and important, insofar as it lists those quality measures which it believes to be most important. They are looking, for example, at chemotherapy patient visits to the emergency department and hospitalizations. Those are the kinds of measures that payers are thinking about when they think about value in cancer care. Consequently, those are measures that providers really need to be attuned to and increasingly aware of their performance on.”
Of course, many oncology practices are experimenting with new payment systems through contracts with private payers--but those contracts generally affect only a small subset of their patients. Do you think oncology practices are well-positioned to move to a new payment system for a majority of their patients? Why or why not?
Conway: “The answer is yes and no. Yes, insofar as I think every oncologist I’ve talked to is genuinely committed to delivering evidence-based, coordinated, patient-centered care for their patients. I think a lot of those elements will be critical and foundational to success under any of these new kinds of payment models.
“But, of course, that’s not going to be sufficient in and of itself. Change is hard, and there is a lot of change playing out in our industry right now. Moving to risk-based contracting, as Rob said, essentially requires flipping our old business model on its head. So, it’s hard to do.
“As we look across the country, though, those practices that seem to be having the most success do share certain characteristics in common. The first is the fuzziest, and it’s a cultural quality, if you will. It’s a willingness to look critically at your performance today and to measure it. Also, it is a willingness to make changes towards more standardized care processes.
“The second characteristic that we see as really critically important is data analytics capabilities. That is the ability to understand at a very detailed level what your costs are, what your quality performance is--and to benchmark that, ideally against others across the country. Also, of course, there is the challenge of integrating data from across multiple IT systems.
“The third characteristic that I would call out to you is, again, a kind of a provider mindset, if you will. And that is an across-the-continuum perspective. That means a willingness to focus on not only how do we improve the care that we provide our cancer patients within the scope of our practice, but also how are we partnering with our colleagues in primary care or other specialties to help shepherd their patients through the diagnostic process and ensure timely access to cancer care? And then, of course, during active treatment, how are we working with the various supportive care professionals and other health care professionals that may be involved in caring for our cancer patients, ensuring coordination, avoiding duplication of services, and so on?
“And then, on the back end, thinking about survivorship care. We are in the very fortunate position of having a growing population of cancer survivors, but, of course, we don’t necessarily have resources that are growing at corresponding rates to care for those survivors. How can we partner in creative ways with primary care and other specialists to make sure that those patient needs are being met, and most importantly, that we are doing everything possible to minimize their risk of recurrence, secondary cancers, or other complications as a result of their initial cancer diagnosis?”
What should oncologists and oncology practice managers be doing right now to prepare for the payment changes that are coming down the pike?
Conway: “I think there are several steps that oncology administrators and practice managers and physicians can be taking. The first is that it is really important to stay attuned to the dynamics that are playing out in your local market. Are there new ACOs cropping up in my market? What kinds of contracting strategies do payers and providers in your market seem to be pursuing?
“It is also really important to open the conversation with your payers. What’s their oncology strategy? What are they worried about? Where do they see opportunities to improve quality and cost? And what are the opportunities that might exist to work together towards those goals? That could be piloting a new payment model, or it could be simply working together to share data about performance and look for opportunities to improve.
“I think it’s always important, and continues to be important, to look for opportunities to standardize operations and care processes in order to control cost, whenever possible, and ensure evidence-based practice.
“Also along those lines, I think it’s critically important to invest in building out a quality performance monitoring and management program. That is hard, for the reasons I mentioned earlier, because we don’t have a broad set of validated consensus-based oncology quality measures. But there are oncology quality measures out there, and as I said, I think it’s very instructive to look at the list that CMMI has put on the table (scroll to page 6) as being important. And I think providers really need to work into part of their practice regular reviews of their performance on these measures, and discussions about how they can be doing even better.”
Lazerow: “From a strategic perspective, I would encourage them to be thinking about being able to answer two questions. First, who are the new ‘purchasers’ of our services? Is it a new physician ACO, as Lindsay referenced? Is it a hospital that’s exploring bundled payments and might looking for us to provide that care? So, who’s actually going to be buying our services and fueling our growth in the future?
“Second, how do we demonstrate value to them? Is it about efficiency across a particular episode of care? Is it about managing patients over time? How do we document and demonstrate that value?
“I believe being able to show that value proposition will be absolutely critical to growing in this new value-based payment world where there’s a lot more scrutiny from all the purchasers, and, by the way, a lot more purchasers making those decisions.”
Conway: “And what we find is that the different purchasers – your payers, your patients, your referring physicians, etc. – they are all defining value in cancer care in slightly different ways. Obviously, those differences can be really critical to having a successful partnership with them and being able to attract their business, so to speak. So it’s really critical to get to know the key players here, and how they are thinking about cancer care, and how you, as a provider, can better meet their needs for high-quality, low-cost care.”