SAN DIEGO – If you consider participating in an alternative payment model for your practice, expect to devote a lot of time to work flow changes, according to Blase N. Polite, MD.
“The culture change is one of the hardest things people face as they go into alternative payment models,” Dr. Polite, deputy section chief of clinical operations at the University of Chicago Medical Center, said at the annual meeting of the American College of Physicians.
“You want work flow changes designed to enable you to take better care of your patients in a consistent manner,” he noted. “It has to be designed with a busy clinic and a busy clinician in mind. You want to be able to share the work flow burden among different groups in the system, so it’s important to allow individuals to work at the upper end of their training.”
, an internist who is also executive medical director for cancer accountable care at the medical center, shared his experience with joining a voluntary Centers for Medicare & Medicaid Services oncology care model of 190 practices in July 2016. It’s framed around a 6-month episode per patient that begins when IV or oral chemotherapy is administered.
“We are paid $160 per month throughout the 6-month episode, and you can have as many recurring 6-month episodes as needed, assuming the patient continued to receive chemotherapy in IV or oral format,” Dr. Polite said.
“Our management fees are contingent on documented adherence to care processes,” he added. “We are held accountable to cost of care, quality metrics, and care processes. The shared savings are subject to bringing down costs while maintaining quality. If by year three you have not achieved shared savings, you have two choices: either drop out of the model, or agree to two-sided risk.”
CMS also is collecting detailed stage, molecular data, and recurrence/progression data on each patient.
The ability to perform risk adjustment in your patient population is a cornerstone of any alternative payment model, he said. These include variables such as cancer type, age, sex, selected noncancer comorbidities, receipt of radiation, and participation in a clinical trial.
As an example, Dr. Polite discussed the hypothetical case of a 65-year-old man with lymphoma, Medicare Part D coverage, and no Medicaid.
“If that patient has no comorbidities, the target treatment price is $23,657.80,” he said. “If that patient has been coded for three comorbidities, our target price goes up to $32,090.28. So, you see an almost $10,000 difference in our target price based on whether or not you appropriately coded and accounted for comorbidities in your patient.”
In a 6-month period, about one-third of costs in the university’s oncology care model are related to chemotherapy, another one-third are inpatient costs, “and everything else comes out as rounding error on the back end, such as evaluation and management coding, imaging, and radiation therapy,” Dr. Polite said.
CMS periodically sends national data such as the number of inpatient admissions per 100 patients and ED visits per 100 patients, so the center can compare itself with other practices in the model.
“You have to have a way to think through those data,” he said. “We can look at our drug expenditures and see where it is we’re spending the most money. Are there places where we can save money? Another key area: How do you identify your high-risk patients?”
Currently, Dr. Polite and his associates conduct risk assessments with every new patient, including the Vulnerable Elders Survey (VES-13), the Mini-Cog, the Patient Health Questionnaire–4 (PHQ-4), as well as questions intended to gauge the patient’s social support, financial situation, and health literacy.
“This is triggering within the medical record a best practices alert that is telling the physician there is a recommendation that this patient ought to be referred to social work or geriatric oncology, or psycho-oncology or physical therapy depending on their needs,” he said. “What remains a difficulty is we have about 18% of our patients who have a positive screen. But only in 23% of the cases so far do we have physicians who are actually acting on that screen.”
Clinicians considering adoption of an oncology care model should expect to devote time and resources to additional cancer registry abstraction and data entry, and make electronic medical record changes for data capture and identifying high-risk patients.
“You also want to invest in care coordination and navigation, staffing for after-hours urgent care to avoid emergency department costs, hospitalizations, and readmissions, staffing for pharmacists to manage high-risk patients on complex medications, staffing of additional palliative care providers, and system tools to make sure referral loops are closed,” Dr. Polite said.
“Those are places where money can help you,” he added. “But at the end of the day, money cannot help getting all the staff to collect and act upon the information provided to them.”
Dr. Polite disclosed that he has received research grants from Merck and is a consultant for GLG and Pfizer.