Care Management Programs vs Value-Based Programs: The Path Forward

Barry Russo, MBA, The Center for Cancer and Blood Disorders, spoke with Brandy Manning, MSN, RN, OCN, Alabama Oncology; Amy Valley, PharmD, Cardinal Health; and Tanya Park, Cardinal Health; about why many oncology practices opted out of the Enhancing Oncology Model and what tools and resources they can use to still participate in a value-based approach to cancer care.

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Read the full transcript:

Barry Russo, MBA: Hi, and welcome to Cancer Care Business Breakthroughs, a video series in which we host conversations around cutting-edge developments in the business and financing of cancer care and health care in general.

I'm Barry Russo, the CEO for The Center for Cancer and Blood Disorders in Dallas–Fort Worth, Texas. Our practice consists of almost 40 oncology providers, and we’ve been involved in value-based care for a long time—since 2009 and the initial United episode fee program, the COME HOME program with Dr McAneny and her team, which was the project that began the design of the OCM model.

In today's edition of our Business Breakthroughs video series, we will be exploring the distinction between care management programs and value-based programs. What are the implications, if any, of the relatively limited participation in the Enhancing Oncology Model program? And how might that inform CMS on future views of value-based alternative payment models?

Today's panelists are Amy Valley, PharmD, Vice President, Clinical Strategy and Technology Solutions for Cardinal Health; Tanya Park, Director of Innovation Technologies, Cardinal Health; and Brandy Manning, Director of Quality and Value-Based Care for Alabama Oncology.

Before we hear from our panelists, let me clarify some terminology. By care management programs we mean Medicare-sponsored programs in which providers and practice staff can deliver enhanced care to patients and be reimbursed for doing so. Programs such as Principal Care Management, or PCM; Chronic Care Management, or CCM; Transitional Care Management, or TCM. We've done many of those in our practice, and I'm sure many other practices across country you're either doing these programs or you're involved in starting up these programs—super important.

By value-based programs, we mean both government-sponsored programs, such as the Enhancing Oncology Model, or EOM, as well as commercial payer–sponsored programs, which seek to reimburse based on overall value and cost management of an episode of care. There are many of those around as well with Aetna, Humana, and many of the payers out there, and so much more so these days in Medicare Advantage.

So, let's start by asking Brandy, and then we'll go to Amy and Tanya. Your practice, Brandy, passed on being a voluntary participant in EOM, as did ours as well as many other practices. Can you talk about what some of the main drivers were for that decision at your practice?

Brandy Manning, MSN, RN, OCN: Thank you, Barry. Yes, we did pass on participating in the EOM, and we consider our practice to be forward thinking and value focused. We have 22 physicians and 6 APPs in community oncology, and we participated in the OCM even before EOM, to gain more insight into how our practice operated, and how it would perform at a value-based care program, and we were very pleased with our performance and what we learned from that.

But I think our hesitancy and ultimate decision not to move forward with the EOM was that with the OCM we had time to evaluate and assess the model and even acclimate before the two-sided risk requirement. We felt honestly that the EOM was rushed to try to accommodate the ending of OCM.

But also with fewer disease states and the reduction of the MEOS payment by more than half meant that we were looking at about a third of the revenue but with an increase in reporting requirements and just a greater demand and strain on our resources. I think investment wise, it just didn't make sense for us, but we are excited to hear from the practices who did volunteer and what they're learning to advance cancer care.

Russo: Yeah, I agree, Brandy. We looked at the same things when we were looking at it, and I just couldn't make it make sense for us, just like you guys did. Amy and Tanya, you both get the chance to see and hear from a lot of community oncology practices across the US.

What have you observed as some of the misses in the EOM model, which decreased participation? And have you seen increased practice interest in other programs, like CCM and PCM, as a result of those that are not participating in EOM?

It's only a small volume of 40 or so practices that actually are in EOM—what's everybody else doing?

Amy Valley, PharmD: Yeah, I think our focus here at Cardinal Health has been investing in solutions to help community oncology practices be successful in a value-based reimbursement model. So, like many, we're really looking forward to the next iteration. And also, we're just sort of just disappointed that we are where we are, with so few practices not proceeding with EOM.

I do think there were a few things EOM got right; I do think focusing on higher-risk cancers, reflecting the importance of SDOH, incentivizing adoption of ePRO technologies were good things, but I think Brandy said it well; I think the major mess was in requiring the two-sided risk out of the gate and not allowing some run-in period to understand new baseline data, new calculations, methodologies in this new model, and it just led to so much concern over how things would be measured, would there be adequate adjustments for novel and innovative therapies, etc? So ultimately, too much uncertainty and risk.

So, those are some of the major determinants that impacted the decision of so many practices. We certainly have seen an interest in Chronic Care Management, Principal Care Management, and Transitional Care Management reimbursement, and those who haven't already been doing that are very interested in exploring that. And so, we've expanded our own solutions to be able to meet this need.

Tanya Park: Yeah, I think, Amy, you've said it very well about where a lot of the practices were, as did Brandy, in terms of those challenges, and I think you know, we may have seen a lot of practices continue if the model had been closer to OCM and it was what they were expecting. You almost had a brand-new approach with EOM, and that definitely led to that uncertainty.

I think the other piece is administrative burden for practices with only having those 7 cancer types, and only those patients on chemotherapy treatments, it just made people try to figure out, how am I going to manage this split population from the administrative side, and that even those practices continuing with EOM are going to be faced with that challenge of, you know, 7 cancers in this, but what do I do with everyone else? Which has led to the interest of what could replace MEOS for the patients. I want to treat everyone the same. I want to have that same clinical set of services for patients that was very successful in OCM. I think that's the one thing that was a big highlight is the benefit to patients. And so now you're really thinking about, how do I keep that benefit to patients and still get reimbursed for those services? Which is where these care management programs, which have been around, come into play.

Russo: No, I appreciate that. Brandy, given the discussion about CCM, PCM, TCM, can you talk about what it's been like at your practice implementing the care management program—CCM, PCM, and TCM—what tools you found to be effective and how you guys have gotten it off the ground?

Manning: Yes, absolutely. Once we made the decision not to move forward with the EOM, we really just wanted to keep the momentum that we had gained from OCM going with MIPS, MVP, and other future payer models focused on quality and value. We were looking for ways to support all of the elements and resources that we had already put into place.

At Alabama Oncology, we can sometimes follow a crawl, walk, run philosophy, and we don't always have to be first, but we do want to always be progressing and moving forward, and especially when it comes to patient care. So, anytime we can provide a great service that improves our patient care and at the same time reduce costs. I mean PCM and CCM just seemed like the logical next steps for us.

One thing we did learn in our value-based care participation was that our highest risk patients and most complex patients accounted for most of our health care costs. So, we knew going forward that we wanted to start our focus on those patients, and we had risk-stratification processes implemented during our OCM. But we really needed tools that we could use to support those processes and also screen to identify PCM- and CCM-eligible candidates. For that, we use our EMR report capabilities along with Navista performance insights. And after we identified our eligible patients, we really began developing our workflows. Patient consents, calls, tracking, documentation, and what our interventions were going to look like.

And during that implementation phase, I think it just kind of helped us shift our focus primarily to PCM. Being a specialty, PCM requirements are just very straightforward. Less risk of other providers billing for the same service. So, two of our physicians really stepped up, and were very supportive in the initial launch and allowed us to test it out on their patients and really helped us to streamline what our processes were going to look like.

And then, of course, our EMR reports forms we’re tracking; we wanted to have those built in just for PCM. And they would be more easily accessible for the physician care teams to have everything right there available to them in the EMR. But along with that, we use Cardinal Health’s Navista TS, and that really just helped us to elevate our service offering for our patients.

Advanced analytics just provided our care managers with so much more patient detail and information. We especially like how the Navista performance insight makes it easier for us to track and monitor our practice’s utilization of care coordination services and any billing opportunities.

Russo: That's awesome. So, you guys are primarily using PCM, at this point. Right?

Manning: Yes, that's correct.

Russo: Got it. Amy and Tanya, can you talk about—as Brandy mentioned, she's using some of the services at Cardinal. Can you talk about the strategic and technology innovations at Cardinal Health that enable oncology practices like Alabama Oncology to more easily deliver care management services and execute billing? That's what we're all worried about, right? Can we get it all tracked and can we get the claim sent out? Particularly in relation to CCM and PCM.

Park: That's one of the challenges practices have with how to make sure, if you're doing care management, you're actually getting reimbursed. How do you track, you know, what's been billed and not billed? And what we saw at Cardinal Health was there are lots of great solutions out there for tracking time and managing your clinical workflows around care management. There was a lot of support in that area already out there for practices.

But where there was a gap was really understanding what got out and got billed. And so, you've enrolled this patient in PCM, and you build that first month. Well, did you keep billing month after month? You're probably spending that time with the patient. But are you actually continuing to bill for that.

So, many of those systems that track time, they only track the time that you spend with those patients. And so, if you miss patients in there, you're actually missing a lot of opportunities to continue billing these services. And if you're a practice that wasn't OCM, and you're kind of looking at care management as a MEOS replacement, right, you want to bill month over month.

And so, with Navista TS, and our performance insights product, you are actually able to pull that up and see where you have those missed billing opportunities and go ahead and then submit the claims for any of those areas where patients may have fallen through the cracks from a billing perspective. So that really ensures practices can maximize their reimbursement in these areas.

Dr Valley: I think that's a great description of what we have today: a really important connection to maximize the results. Not just from a care management, but from a financial ROI point of view, I think as we look downstream, there's a tremendous amount of innovation that is ongoing. I'm sure practices like yours, Barry and Brandy, are being approached all of the time with the latest new tech, and I think we look at part of our role as being a partner with our practices to help vet some of these technologies and to really push the envelope on interoperability and affordability. Because the innovation’s great, but every time we add another tech, there's another cost, there's integration time, it's got to fit into the workflow, etc. And so, we really take that part very seriously, as we're looking for the next elements and innovations to add to our Navista portfolio.

Russo: That's awesome. I so appreciate it. I just left a meeting, actually, where we were talking about CCM and PCM. The meeting was with a bunch of other administrators from other practices, not oncology. So few are doing PCM and CCM and have any infrastructure or structure to do so. Although they are incurring all the same kind of time with patients, just no way to track it. So, having some tools such as you're describing is so helpful in oncology because we spend so much time communicating with the patients, so greatly appreciate it.

So, for the panel as a whole, and I'll start with Brandy, for these programs—PCM, TCM—that you described, can you comment on the value to the patient and the value to the practice? What's involved in the practice operationally to accommodate care management programs, and what do you think the ROI is going to be for Alabama Oncology? And for the other practices, Amy and Tanya, that you guys work with?

Manning: Yes, that's a great question. We're a quality certified practice, and we feel, probably like most everyone in the oncology care community, that we have a good handle on our patient care and coordination. We have had some really positive feedback from our patients that leads us to think that the value for the patient for us, so far, has just been an enhanced patient experience. They get to know and recognize the care managers who are calling on them, and they're reassured that someone is looking out for them.

Their conversations with the care managers, just has a dialogue, and we ask them for their feedback, since these are new processes for us and them. And of course, anytime you ask a patient for feedback, well, they're going to give it to you, so you better be prepared to take it and receive it. And we have. And we have had the ability to take those opportunities and everything that they've given us to help promote our continuous quality improvement efforts.

During the calls, our care managers, they're assessing them clinically but also assessing for social needs or financial concerns, and we ensure that they're compliant and fully understand their care plans. And especially with our oral chemo patients, I think we've had the best reaction from our physicians utilizing it for our oral chemo. The care managers were able to take on the responsibility for the oral chemo adherence and monitoring. So that was previously on the physician teams.

We've been able to utilize and stabilize acute issues or conditions that were risk factors for emergency department visits and hospitalizations, which impacts overall health care costs. And even though we're not participating in the EOM, this definitely helps us in the MIPS cost category, which is at 30%, as part of our MIPS score right now.

So, I think I would have to say, the return on our investment has really just been a great patient experience, improved quality metrics, patient compliance, and early identification and intervention of the patient issues that just kind of ultimately leads to lower health care costs and MIPS performance.

Russo: Awesome. Amy?

Dr Valley: Yeah, I would say, thinking about what each practice needs from an operational point of view. Each practice truly is different. The workflow, their technology footprint—so many things vary. So, I do think an individual assessment is really important to develop the right operational plan. I think that the available resources practices have to start new programs also varies by their size and what other types of initiatives that they have ongoing.

I think Brandy remarked on this earlier, but for practices that were already in OCM, it was an easier transition for them to start thinking about how to initiate CCM and PCM; they're using some of the same resources and practice transformation they had already made in order to get those programs started.

However, Barry, you commented, there's a lot of practices that haven't even started. And I think many of those are the practices who feel really overwhelmed. Maybe they weren't in OCM. And as they read the requirements of CCM and PCM, or they're thinking about new technologies, it's just as overwhelming. And that's why we've taken an approach of not just having a technology offering, but also support services, consultative services, etc, to be able to better support practices in getting a program successfully started.

Russo: Great. Tanya, your thoughts?

Park: Yeah, well said, Amy. I completely think that this is practice by practice in terms of what's needed operationally. I love, Brandy, how you kind of have that crawl, walk, run philosophy with getting started. Because, you know, you don't have to do everything at once to start PCM or CCM or these care management options. Some practices just do TCM because they want to look at those patients who have been to the hospital and are coming home and help with that transition of care. So, I think there's a lot of different flavors here to let practices start.

The other thing I’ll add operationally is there are a lot of options to outsource portions of care management or have the ability to augment your existing practice staff by using other services. So, you don't have to do this alone as a practice. You don't have to hire to get started, and you could start doing just a portion vs having everyone at once in your practice have to start doing these outreach services.

Russo: That's a great point. I will say I'm with you, Brandy, that one of the things that we really felt like with OCM was that we were connecting with the patient more often, and the more often we connected the better the care got and the better the coordination of care got. And I think CCM, PCM, TCM, all that potentially continues that process and at the same time provides some level of ROI for the effort put into it. I just think we're taking better care of patients, which is ultimately what we all want anyway, right?

But a final thought: What, if any, common misconceptions have you run into with regard to either care management programs or value-based care in oncology? Brandy, we'll start with you.

Manning: Yes, and as Amy mentioned earlier, we were fortunate. We were able to utilize some of our staffing resources that we had in place from OCM that allowed us to maintain those positions. But I think one misconception that we had initially was that it would require a lot of additional staffing. Our PCM care managers, again, like I said, were able to reduce the burden on some of the physician teams and taking on some of the other workflow processes from our oral chemo compliance and they're handling that for all of our PCM patients. And it looks to be tracking that we are seeing already a decrease in our patient call volume. Just when you start providing these extra phone calls to the patients and those extra interventions. It looks like our nurse triage phone calls are already tracking to be on the lower side. So, we're going to continue to monitor that. Another one for us was that it would be difficult to bill for, and so far that has not been the case. The requirements are clear, and the billing has been surprisingly straightforward.

But probably the one that has surprised me the most is that the patients wouldn't want to participate if they have cost sharing or a copay. I think that because we're in oncology and cancer care is just so complex, that many of the patients really want that sense of connection with someone. And they really appreciate that next-level support that they're getting with these programs. Like you mentioned earlier, Barry, it's especially this target population that we're focusing on, because they just have so many complex chronic conditions. Honestly, I think they're just relieved to have the help and the guidance.

Russo: Yeah, I'm with you, Brandy. We've had great uptake on CCM, PCM, and TCM. I think the patients really do appreciate it. Like you said, it was a misconception in our part, too, that we would have little uptake. We've had actually had really good uptake like you had. Tanya?

Park: Yeah, I was going to second that, that one of the things was that patient consent piece, and I'm glad you both spoke to that as it being something that patients welcomed. I think that is really important for practices to recognize, and that patients will like to have these additional services and additional contact with their practice, they will feel well taken care of.

I think the other piece that is really common is the staff, right? And so, what we've seen with OCM practices that are now doing this, this is the easy way to keep your staff and make sure that you don't have to lose anyone. And for those practices again, that are short staffed again, that outsourcing model, or starting small and seeing what changes in your practice as you add these programs, like Brandy said, sometimes that shifts demand across one of your practice areas that may be unexpected as you start to utilize these care management services.

I think the last thing I will comment on in terms of misconception is this idea that someone else that the patient is seeing is already billing for these services. That was really common with CCM, where you had primary care, other specialists in place, that were already billing for CCM, and you don't want to step on someone else's toes by adding these services to your practice. I think we're seeing that with PCM, that's less likely to happen. And also that hurdle with CCM, where you have to have two or more diagnoses to qualify and enroll. It was just a lot more complexity in terms of that qualification process with patients and principal care management really simplifies that down and also will apply to the majority of the practice’s patients.

Russo: That's good point, Tanya. We were super worried about that, too, that we would be stepping on toes and other people would be involved. And what we found, well one with PCM, you don't really have that problem. But also, we also found there was not a whole lot of uptake in our market on the primary care side on CCM. And so, we weren't stepping on toes. And again, I think, as Brandy mentioned, we really were, I think, providing better care. Any time we're talking to the patient more often, we're providing better care. So, Amy, final thoughts?

Dr Valley: Yeah, I really appreciate the discussion today. So many good points have been made. I think, a final thought on misconceptions that we commonly hear generally for value-based reimbursement programs is, it's too late. That if I haven't already started, that it's just too late for me to do anything in my practice to be prepared. And that's just not true. I think we have to consider that these programs thus far have been voluntary, and if you look at the CMS roadmap or CMMI roadmap over the next few years, these will eventually become mandatory programs.

So, I think a good starting place is always to just incorporate some analytics to really understand your patient population. Understand those cost drivers where you may be benchmarking in a way that's off target with the rest of the oncology market, or at least in your region. So just understanding your patient population’s cost drivers is always a great way to start, not just for government-sponsored reimbursement programs but also those with commercial payers. So, it's not too late. And I'd certainly encourage practices who want to get started to reach out to us. We're always happy to talk with you, no matter where you are in your journey of value-based care.

Russo: I'm with you, Amy. It's never too late, right? There's opportunity out there. So, I appreciate the efforts on Cardinal's part.

That’s about it for today for this Cancer Care Business Breakthroughs session. I'd like to thank our panelists; it’s been a great discussion, I so appreciate it, and their insights have just been really, really helpful.

We look forward to building on this conversation and many more in upcoming videos as well as during our upcoming annual Clinical Pathways and Cancer Care Business Exchange Conference, October 6-8, in Boston.

Thank you for all your interest in our Cancer Care Business Breakthroughs video series, and we'll see you at the next one.