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    Charles Saunders
    Charles Saunders, MD
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    Neal Shore, MD, FACS

    Many practices are entering their second performance period under the new reimbursement models evolving from regulations tied to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), while awaiting their 2017 performance results.

    Evidence suggests that these same practices may feel at best proficient, albeit not fluent, in value-based care’s requirements and implications. A recent survey by Integra Connect of practices representing 800 specialists found that more than 70% said they “have a way to go” in mastering value-based care, while 56% noted that financial analytic success will require a significant transformation of their practice patterns.

    For many practices value-based care has come through participating in the Merit-based Incentive Payment System (MIPS). However, advanced Alternative Payment Models (APMs) can offer an attractive alternative. Advanced APMs focus on episode groups based on conditions or procedures, offering the opportunity for practices to consolidate value-based care efforts around high-impact areas of their practice. Advanced APMs have the further benefit of exempting practices from MIPS, while simultaneously promoting higher-quality care.

    Unfortunately, there remains a significant challenge: Only seven APMs were approved in 2017, limited to a handful of specialties such as orthopedics, oncology and cardiology. Most other specialties had no options and thus had to participate in MIPS instead. Consider urology, where fewer than 1% of specialty physicians participated in an advanced APM (less than 100 of the more than 10,000 practicing urologists).

    While the Centers for Medicare & Medicaid Services (CMS) has taken steps to expand advanced APM options, some medical societies and associations have decided to be more proactive. These groups are banding together, and with industry sponsors, generating advanced APMs for their stakeholders. They are constructing the advanced APM methodology and eventually attempting to process it through the governmental review algorithm.

    For example, the Large Urology Group Practice Association (LUGPA) spearheaded one such effort alongside industry partners Integra Connect, a provider of value-based care technologies and services, and Myriad Genetics, a developer of genomic assays assessing prediction and prognosis of cancer cares. LUGPA’s leadership embraced an opportunity to provide high-quality, value-based care for the treatment of localized prostate cancer.

    Specifically, clinical guidelines increasingly reinforce the clinical belief that many patients diagnosed with localized prostate cancer can experience equivalent outcomes with a regimen of “active surveillance” in lieu of “active treatment.” Instead of an immediate and invasive intervention such as radiation therapy or prostatectomy, appropriately selected patients can choose active surveillance while receiving judicious monitoring and testing, and avoiding unnecessary treatment.

    Active surveillance patients sustain quality care while avoiding the potentially debilitating side effects of an active interventional therapy. Thus, the healthcare system also benefits from substantial cost-efficiencies. LUGPA analysis estimates that its active surveillance APM will save more than $20,000 per episode of care in a Medicare population, which will result in even greater savings in a commercially insured population.

    As the LUGPA APM effort progresses through the governmental review process, the feedback and analysis provides information about value-based care payment models. The Oncology Care Model (OCM), launched in 2016 by the Center for Medicare & Medicaid Innovation (CMMI) among 196 practices representing approximately 3,200 oncologists, seeks to provide higher-quality, more-coordinated cancer care at a reduced total cost.  

    At the center of the OCM is the strident belief that practices must transform clinical and financial pathways to successfully assume holistic responsibility for their patients. This will require that practices consider an array of investments, inclusive of care navigation, management capabilities of new data and novel analytical technologies.

    As a result, the APM model is oriented toward equipping practices with a new infrastructure while providing incentives for successfully achieving both clinical and financial outcomes. Participating practices, therefore, receive a $160 per member per month payment during qualifying six-month episodes of chemotherapy and may participate in the promise of shared savings when specified cost benchmarks are exceeded. Other efforts, including LUGPA’s APM, have emulated this value-based approach.

    Should your practice support one of these efforts or, if no relevant initiative exists, band together with other stakeholders to establish its own APM? Important criteria to evaluate in an advanced APM include:

    • A high-impact condition or procedure that affects a large volume of patients or generates a significant percentage of practice revenue
    • Alignment with clinical science and data
    • Existence and/or development of related quality measures that are meaningful to physicians, patients and payers
    • Ability for physicians to positively affect key cost drivers
    • Potential for significant CMS financial savings without diminishing clinical outcomes

    While MIPS and advanced APMs are naturally oriented for clinicians and patients, medical practice managers should recognize the important role they can play in the success of their practice’s value-based care. As practices evaluate and pursue opportunities, practice managers can ensure successful participation in an APM by:

    • Educating and promoting. The surveys cited earlier reflect a continued lack of understanding of value-based care and its far-reaching impact on practices. Practice managers are well-positioned to bring clinical and operational peers up to speed, advocate the importance of adoption, and inform their peers of options and potential best practices to emulate.
    • Informing and influencing. As new advanced APMs are designed or existing ones evaluated, practice managers can help identify the practice process/procedural gaps and requirements to meet performance goals operationally and financially. For example, those participating in the OCM have played an essential role in ensuring expanded patient accessibility to their practices, as well as assessing new technology and staffing to support care teams.
    • Mobilizing and measuring. With their connection to the practice revenue cycle, practice managers can help ensure the alignment of measures tracked by physicians with the metrics that payers will hold practices accountable. As payers report back on performance period results, practice managers will also play a key role collaborating with clinical peers to translate areas of over- or underperformance into further operational optimization.

    As practice managers help steer their practices into the value-based care transition, many are looking to advanced APMs, which will enable them to achieve beneficial quality and cost improvements efficiently to assist patients and their practice management. Those who do not have access to an existing APM must forge their own specialty-specific APM, as the example of LUGPA demonstrates. Whichever path a practice chooses, its clinicians and practice managers will contribute to its success together.

    Charles Saunders

    Written By

    Charles Saunders, MD

    Connection@mgma.com


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