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Practice Survival in Today’s
Oncology Ecosystem
Strategies to effectively address business
challenges facing practices today
POHMS 4th Annual Spring Conference
King of Prussia, PA
March 10, 2017
Elaine L. Towle, CMPE
Division Director, Analysis & Consulting Services
571-483-1616
[email protected]
No disclosures
2
The Ideal
3
The Reality
•
•
•
•
•
•
•
•
•
•
•
Pathways
Preauthorization
Denials
Cost of drugs
Bad debt
PQRS
Meaningful use
Staffing
Competition
RAC Audits
MACRA
• And on and on and on…..
4
Practice Pressures
Increasing Facility Expenses
Drug Pricing
Payer Pressures
Electronic Health Records
Competitive Pressures
Staffing Issues
Clinical Research
Patient Ability to Pay
Local Economic Pressures
Genomic Testing
Other
Drug Shortages
0
Academic Practice
5
10
15
20
Physician-Owned Practice
25
30
35
40
45
50
Hospital/Health System
Source: ASCO Annual Practice Census 2016
5
Practice Pressures: Physician-owned
practices
Drug Pricing
Increasing Facility Expenses
Payer Pressures
Competitive Pressures
Electronic Health Records
Staffing Issues
Patient Ability to Pay
Clinical Research
Genomic Testing
1st Highest
Local Economic Pressures
2nd Highest
Other
Drug Shortages
0
5
10
15
20
25
30
Source: ASCO Annual Practice Census 2016
6
Administrative Burden…
It’s Not Just Your Imagination
March 7, 2016
7
Administrative Burden
Which pathway??
Payer
B
Payer
Payer
E
F
8
The Result?
56%
48%
43%
38%
Physician-owned practices
Source: ASCO Annual Practice Census 2012-2015
9
Community Oncology Alliance
2016 Community Oncology Practice Impact Report:
Tracking the Changing Landscape of Cancer Care
10
Special Concern for Smaller Community
Practices (1-5 Oncologists)
• Backbone of U.S. cancer care
delivery system
20%
• Serve more than one-third of all
new patients, especially in the
South
• Smaller practices more likely to
merge, sell, or close in the next
year
– 16% Merge
18%
16%
14%
12%
Merge
10%
Sell
8%
Close
6%
4%
2%
0%
– 12% Sell
Midwest
111 practices
Northeast
70 practices
South
West
142 practices 125 practices
– 10% Close
Source: ASCO Annual Practice Census 2014
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12
13
Medicare Provider Reimbursement
MIPS
APMs
Sustainable Growth
Rate (SGR)
1997
2015
2017
Medicare Quality Payment Program (QPP)
APMs
MIPS
Merit Based Incentive
Program System
• Measures Quality, use of CEHRT,
Improvement Activity and Cost.
• Peer Comparisons
• Incentives/Penalties
• Publicly Reported
Alternative
Payment Models
•
•
•
•
New Payment Mechanisms
New Delivery Systems
Negotiated Incentives
Automatic Bonus
Will It Affect Me?
1st time Part B
Participant
Medicare Part B
(Physician
Services)
Low Volume( $30K ) or
Low Patient Count (100 Patients)
APM Qualified
Participant
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How Will Medicare Reimbursement Change?
The Merit Based Incentive Payment System (MIPS)
Legacy
Reporting
Systems
Physician Quality
Reporting System
(PQRS)
Meaningful Use
(MU)
MIPS
Consolidates penalties
MU
PQRS
Increases incentives
Ranks peers nationally
Reports publicly
Value Based
Modifier (VBM)
17
How Will Medicare Reimbursement Change?
The Merit Based Incentive Payment System (MIPS)
Legacy
Reporting
Systems
2016
Last Reporting Period
2018
Last Payment
Adjustment
MIPS
2017
Adds Improvement
Activity
First MIPS
Performance Period
2018
Cost category Scored
2019
First MIPS Payment
Adjustment
Cost
Not included in 2017
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MIPS Payment Adjustments Timeline
+/4%
2019
2018
2016
2017
+/5%
2020
+/9%
2022+
+/7%
2021
2021
2019
2030+
2025
2020
2024
2026
Year 1 = Performance
Year 2 = Analysis
Year 3 = Adjustment
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Pick-Your-Pace for 2017: MIPS Reporting
+%
0%
-%
+%
2017
Don’t Participate
Not participating in
the Quality Payment
Program: If you don’t
send in any 2017 data,
then you receive a
Test the Program



Report:
1 quality measure
or
1 Improvement Activity
or
The required ACI
measures
Partial MIPS Reporting
Full MIPS Reporting
Report for at least 90 days:*
 1+ Quality measure
or
 1+ Improvement Activity
or
 More than the required
ACI
Report for at least 90 days:*
 Required Quality
measures
and
 Required Improvement
Activities
and
 Required ACI
*consecutive days
2018
*consecutive days
Full program Implementation.
2019
Negative 4% payment
adjustment
Avoid penalties
Avoid penalties; eligible for
partial positive payment
adjustment
Avoid penalties; eligible for
full positive payment
adjustment; exceptional
performance bonus
Pick Your Pace in 2017 Transition Year
-4%
Failure to Participate in
QPP in 2017 results in a
Negative Payment
Adjustment
Preparing for 2018
Category
2017 Reporting
Requirements
2018 Reporting
Requirements
Quality
Minimal: 1 measure, 1 patient/chart
Partial: 90 days, 50% of all patients
Full: at least 90 days, 50% of all
patients
Full year
60% of all patients
ACI
Minimal: base score for 90 days
No performance thresholds used in
scoring
At least 90 days
Potential addition of performance
thresholds for scoring
IA
Minimal: 1 activity for 90 days
Full: 2-4 activities for at least 90
days
At least 90 days
2-4 activities
Cost
Full year
Calculated automatically by CMS
0% weight in MIPS
Full year
Calculated automatically by CMS
10% weight in MIPS
Pick-Your-Pace for 2017: APM Participation
CMS Recognized Alternative
Payment Models (APM)
 Exemption
from MIPS
Advanced APM
Qualifying Physicians
 5% Lump Sum
Bonus
 APM Specific
Rewards
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What is an Advanced APM?
CMS Recognized
Alternative Payment
Models (APM)
Advanced APM
Qualifying
Participants
• Requires use of Certified
EHR
• Ties payment to quality,
similar to MIPS
• Meets Financial Standards
• At least 5% of revenues
at risk; or
• Maximum loss of at least
3% of spending
benchmark at risk
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Who is a Qualifying Participant?
CMS Recognized
Alternative Payment
Models (APM)
• APM entities must meet thresholds for
percent of Medicare Payments Received
through, or Medicare Patients in Advanced
APMs
• Partially Qualifying Participants
Payments
Patients
Advanced APM
75%
50%
50%
35%
25%
20%
Qualifying
Participants
2019
2021*
2023 and
beyond*
*Beginning in 2021, other payer APMs may be considered
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Any Advanced APMs in 2017?
Medicare Shared Savings Program (2 Tracks)
Next Generation ACO
Comprehensive ESRD Care (2 models)
Comprehensive Primary Care Plus
Oncology Care Model (OCM) - two-sided risk
track available in 2017
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ASCO Offers Solutions
Certification
•
•
Improvement Activity
APM Participation
Rapid Learning
•
Quality Reporting
Reporting
•
•
•
•
•
Quality Reporting
Advancing Care Information
Improvement Activity
Cost
APM Participation
Reimbursement
•
•
APM Participation
Improvement Activity
Transformation
•
APM Participation
ASCO’s Top Ten List for MACRA
Implementation in 2017
 Pick Your Pace in 2017. Test the program and submit a minimum amount of data to
avoid a 2019 penalty; OR report some data for at least 90 days; OR report full data for at least
90 days. If you do not report at all, you will receive a 4% penalty in 2019.
 Test the program. If you choose to test the program in 2017, report more than the
minimum required number of measures to improve your chances of successful reporting.
And use the end of 2017 – July to December – to practice full reporting for 2018.
 Explore the quality measures on the QPP website. Identify which measures best fit
your practice. Many of the measures in the General Oncology Measure Set are included in
ASCO’s QOPI program.
 Check that your EHR is certified by the Office of the National Coordinator. It
must meet the 2015 certification standards by 2018; for 2017, you may use an EHR certified
to either 2014 or 2015 standards. And remember that you must perform a security analysis to
pass the Advancing Care Information (ACI) requirements in 2017.
 Review the Improvement Activities on the QPP website. See which activities best
fit your practice.
ASCO’s Top Ten List for MACRA
Implementation in 2017
 Obtain your Quality and Resource Use Reports (QRUR). While Cost is not included in the
scoring in 2017, it is being measured and will be reported in the QRUR. It will be included in the scoring
beginning in 2018 so be prepared.
 Ensure data accuracy. Review your QRUR and ensure that the data is correct. It is also important to
review the NPIs for each provider in your practice and ensure they are accurate with the correct specialty,
address, and group affiliation.
 Consider using a qualified clinical data registry (QCDR) to extract and submit your
quality data. The QOPI Reporting Registry, currently in development, will be your one-stop shop for
quality reporting and attestation for ACI and Improvement Activities.
 Evaluate your payer relationships and begin discussions with commercial payers
about value-based reimbursement and alternative payment models. Identify your top two or
three commercial payers and initiate discussions with them about value-based care. Introduce them to
ASCO’s Patient-Centered Oncology Payment (PCOP) model – we are happy to help.
 Prepare your practice and staff for value-based care. Does your staff understand the changes
that are coming? Is your practice culturally prepared for the shift to value-based payment models? Are you
employing elements of an oncology medical home including pathway utilization and ER and hospitalization
avoidance? ASCO COME HOME provides consulting services to help practices transform for new reporting
and payment models.
QOPI is a Viable Tool for QPP Success
• The QOPI platform can be used to report the minimum data
in 2017 to avoid a 2019 penalty
– Available by mid-year 2017
• 2017 is a transition year for the QOPI QCDR to become
electronically functional to be able to report at 60% of charts
for 2018
– Both the QOPI QCDR and the practices will be asked to “test”
electronic reporting in 2017 so all will be positioned to report at the
higher volume requirement in 2018
• If a practice has the electronic capability to achieve 50%
reporting in 2017, they can use another reporting
mechanism and try for a positive adjustment for 2019
Implications of New Congress &
Administration
• Don’t anticipate change in direction
• CMS has been fairly responsive to stakeholders
and physicians
• MACRA was a largely bipartisan bill, but
Congress eager to hear if refinements needed
– May be opportunity for reduction in administrative
burden
– May be openness to delay in some requirements
– Opportunity to raise oncology specific issues
• Check the ASCO
website regularly for
new tools and
resources
• Webinars
• Fact Sheets
• Quality
Improvement
library (planned)
• www.asco.org/macra
CONSULTING & ADVOCACY
EDUCATION AND RESOURCES
Additional ASCO Support
• Practice
Transformation
• Readiness for
Alternative
Payment Models
• Filing Extensive
Comments
For more QPP information….
www.asco.org/macra
www.qpp.cms.gov
So…. what do I do now?
34
Practice transformation is
no longer optional
• Internal reasons
– Become more service oriented for patients
– Provide more effective care for better patient outcomes
– Provide more efficient care for a better practice bottom
line
• External reasons
– Position the practice to be successful in a new payment
environment
– Meet the needs of a changing patient population
“Practice Transformation? Opportunities and Costs for Primary Care Practices,”
Annals of Family Medicine, www.annfammed.org, May/June 2013
35
Start your practice transformation by
becoming more efficient
1. Hire (and keep) the best staff
2. Develop a team approach that leverages
physician time
3. Maximize your use of technology
4. Avoid work bulges
5. Put your practice on a growth mission
36
Hire (and keep) the best staff
• Eliminate grumpy staff
– Don’t hire a bad attitude…. and don’t keep one either
• A positive attitude is essential to efficiency and is a
legitimate job requirement
• A bad attitude will affect everything else in the
practice
– Patients
– Referral growth
– Team work
……. Everything
37
Develop a team approach that
leverages physician time
• Move everything possible off the physicians daily
work flow so he/she can focus on
– Patient care
– Increasing skills/facility with clinical information systems in
practice
• Everyone in the practice should be working at the
top of their license, including the physicians
• Your team will need to determine how to address
work flow issues that result from these changes
38
Maximize your use of technology
• Clinical staff – especially the
physicians – need to maximize
their use of the clinical
information systems in your
practice
– Most practices utilize only about 20%
of the capabilities of both the EHR &
practice management system
• Optimize the use of EHR by
continuous re-training
– Enhance physician & staff efficiency
– Maximize data capture
39
Avoid work bulges
• Utilize the complete time that is available in the
work day/week and distribute the work
• Identify uneven work distribution – very busy times
and very quiet times
• Take control of the schedule, especially in the
infusion suite
– Decrease patient wait times
– More efficient scheduling for nurses, pharmacy staff
– Use the chairs you have all day long
40
Avoid work bulges
• Where do you have the biggest
problems?
– Infusion suite
– Laboratory
– New patient flow
• Study the specific problem, create a
committed team, get input from all
involved and implement changes
– New staffing model? New way to schedule?
– “But we’ve always done it that way…”
41
Put your practice on a growth mission
• You cannot save your way to success, you must grow
revenue
• Gains in efficiency without practice growth = shrinking to
meet demand
– Very difficult; requires cost cutting, reduction in staff and/or
services, loss of great staff and/or physicians
• The growth mission should be
part of your day to day business
operation
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Put your practice on a growth mission
• Cultivate your referral sources
– Do you know who your big referrers are? Do your
physicians?
– You (and your physicians) can’t cultivate referral sources
if you don’t know who they are
– Can your technology help?
• Make the most of every patient encounter
– Positive encounters breed positive feedback
– Negative encounters breed unhappy patients and need
immediate follow up
43
The brave new world: six universal
payment reform elements
1. 24/7 patient access to clinician with real-time access to
patient’s medical records
2. Robust clinical measurement and management
3. Continuous quality improvement based on clinical and
financial information
4. Patient navigation
5. Documented care plan (containing the 13 IOM
components)
6. Treatments consistent with nationally recognized clinical
guidelines
44
Back to Basics….
• Market share
• Management
• Measurement
45
Market Share
New patients
New patients
New patients
46
Management
• Financial
– Monitor/control expenses
– Understand costs
– Retain capital for growth
– Bill for all services provided – are there new opportunities?
• Inventory
– Compare prices
– Monitor underwater drugs
– Bill appropriately for waste
• Payers
– Collaborate; Educate on new payment models
– Know (and follow) your payer requirements – prior auth, pathways,
quality initiatives
47
Measurement
• Revenue cycle
– Audit yourself before others audit you
• Drugs, drug admin, incident to, JW-modifier (SDV)
• Look for missed charges
– Days in AR; days in AR > 120 days
– Denial rate
• Financial/operational
– wRVU metrics – per physician, per location/site, per service line
– Medical revevue/wRVU, operating cost/wRVU
– Staffing metrics - FTE/physician, FTE/wRVU
– Net drug revenue
48
• Hands on help for practices
– Practice management support and resources
– Quality and performance improvement
– Data analysis, measurement, benchmarks
– Payment reform pilots
– New! Practice consulting services
49
Thank you for caring for people with cancer.
Questions?
50