Value-Based Care, Transparency, Value, Data and Alternative Payment Models

The Final Rule, Alternative Payment Model (APM) proposals, and transparency mandates have made it clear that healthcare will be permanently changing. The goal is to standardize quality and value of healthcare while decreasing cost. In theory this sounds acceptable, but the implementation will require practical applications and buy-in from all those in healthcare. In addition, the patient will need to be informed as to what they are paying for.

This effort will require innovation, testing and collaboration. Resistance to this change will result in being left behind, job losses and penalties.

Seema Verma, Administrator for the Centers for Medicare and Medicaid Services (CMS), has outlined a healthcare and health policy agenda to move the industry in the right direction, which includes weekly updates.

For years, it has been clear that the industry is moving in this direction, however, like what is often done, healthcare is comfortable with the status quo and operates in a reactive pattern.

With greater healthcare choices patients are more empowered in their financial responsibility for care. The market must respond to these demands by encouraging patients to shop based, not only on price, but quality as well.

Oncology has a greater opportunity and focus for the value-based care landscape for several reasons:

  • Drug pricing
  • Rising cancer rates
  • Regimented protocols
  • Efficacy and outcomes data
  • Operation inefficiencies
  • Lesson learned from the Oncology Care Model (OCM)
  • Failure to access meaningful data
  • Insurance coverage restrictions
  • Prior authorization limitations
  • Patient hospitalization improvement

A focus of Legion Healthcare Partners is to close the gap between clinical/operational data and claims data to provide actionable datapoints to ensure access to quality care and practice viability.

There are several limitations at various levels that departments, staff and organizations must recognize before meaningful solutions can occur.

  • Current systems do not provide the data in the format needed for consistency
  • Oncology data is still siloed and doesn’t included medical oncology or surgical oncology
  • Operational efficiency still needs to be improved
  • Investments aren’t being made where they need to
  • Clinical knowledge and expertise is required when adopting new software solutions
  • Transitioning to a true focus on palliative care will be necessary
  • The job market will change
  • Investments outside the institution will be required
  • Vendor accountability will look much different

Institutions have a very large gap in understanding task and protocol-based tasks. Having benchmarks and tracking cost through the patients’ care path is possible and will be necessary.

Alignment with those with resources that are available will also be something that some owned/freestanding practices may need to investigate to ensure they have access to the resources, infrastructure and data to remain viable in the value-based care market.

There will also be investments that providers and institutions must make as they take on more risk in the value-based care market. The need for closer to real-time data such as claims data from CMS will be required. This was addressed on the November 4th meeting with CMMI regarding the OCM 2.0 (OCF- Oncology Care First) model. Actionable changes based on this data will need to be made since the practice/providers are carrying more risk, so waiting 18 months for data would not be acceptable.

Th healthcare industry needs to realize that this is not going away. In 2016, the OCM was voluntary. Fast-forward to the recent mandatory RO-APM, which will be more of the norm. CMMI has numerous APM models in place and proposed:

Commercial Payers have already created models on their own and will continue to do so. The price Transparency Mandate (1717-F2) will go into effect January 2021 and will likely expedite the commercial APM models, since the mandate requires the publication of the private payor negotiated rates.

There is still much to learn but establishing baselines, sharing data and collaboration are all steps practices should be taking now.

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