Transforming Oncology Care: What’s Working and What Lies Ahead

16 December 2015 Health Care Law Today Blog

Oncology providers and payors are undertaking bold initiatives to transform our system of “sick” care into a component of the value-based system of the future. The evolving system focuses on proactively monitoring and coordinating care by a team of providers working in concert to deliver care more efficiently and keep patients healthier. From payment changes to rising consumerism and a multitude of technology advances, the current oncology care landscape presents many opportunities and challenges.

Payment reforms in the governmental and private insurance markets are beginning to drive a change from pay for quantity to pay for quality and value. For example, the Medicare Sustainable Growth Rate (SGR) legislative “fix” will begin to reward oncologists with a 5% payment bonus starting in 2018 if they receive a significant portion of their revenue from an “alternative payment model” or “patient-centered medical home.” In addition, The Center for Medicaid and Medicare Innovation (CMMI) will implement the Oncology Care Model (OCM) in Spring of 2016 under which Medicare will pay participating oncology practices on an episode of care basis. OCM offers oncology practices a potential retrospective performance payment for meeting quality measures and demonstrating cost savings. Finally, commercial insurers are also experimenting with bundled oncology payment programs to incent oncology care more to become more coordinated, cost-effective, vigilant, and patient focused.

At the same time, the patient, as the ultimate consumer of health care services, is becoming better informed, more pro-active, and more selective. Today, as a result of governmental and private market “transparency” initiatives, an increasing amount of quality and cost information is becoming available to the public; and patients have greater incentives to make cost-effective choices about their site and providers of oncology care. Some of the factors driving oncology consumerism include provider-based co-pays, increased activism by employer self-funded plans and new medical technologies that give access to a trove of health information and health monitoring services.

At the same time, there is a recognition that the “science” of quality measurement is in its infancy, and there is much still to be learned from “big data.” Further, advances in precision and personalized medicine, new genetic and biologic discoveries, and new drugs and devices will increasingly change how cancers are diagnosed and treated.

Many community oncology providers report feeling that the pace and magnitude of these changes in the oncology landscape are unsettling, have bred uncertainty and are creating a lot of anxiety. Some of the common concerns include:

  • Reimbursement changes
  • Being excluded from narrowing networks
  • Patient incentives to use less expensive providers and specialty pharmacies
  • Losing referral sources as primary care physicians and other specialists align with specific networks
  • The pressure to give up practice autonomy and become employees of hospitals, large multi-specialty groups or health systems
  • The loss of site of service differentials and 340B benefits

In this new consumerist and cost conscious health care environment, there are critical questions to be answered about what innovative strategies and solutions are available to community oncology providers to survive and thrive.

Join us to explore these issues at the 2016 Cancer Center Business Summit (February 24-25 at the JW Marriott Phoenix Desert Ridge Hotel in Phoenix). Attendees will have the opportunity to learn from industry leaders and community oncology stakeholders about the changes occurring in the cancer care marketplace and how oncology organizations are responding to those changes. Visit the Cancer Center Business Summit website to get more information and to register.

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