Over the past five years, rapid consolidation has occurred among healthcare providers, driven in part by the Affordable Care Act. The pace of consolidation shows no sign of slowing down, “transforming the healthcare marketplace into a land of giants,

This trend also applies to oncology, as more and more community-based oncology practices are joining large health systems. Remaining independent has become much harder for many reasons, including competition from large healthcare organizations and payer consolidations that make negotiating difficult and managing a practice more complex. However, many studies have verified that treating patients in community-based clinics as opposed to outpatient hospital settings results in significantly lower costs to both patients and Medicare. One study found that Medicare spending for patients receiving chemotherapy in a community clinic is 14.2% lower than the hospital outpatient department (HOPD), providing $623 million in annual Medicare savings.

 Another study found that drug costs were between 25% to 47% higher in the HOPD than in the physician’s office.

Sound Business Strategies Support Independence

As these studies show, independent practices play a crucial role in slowing the rise of healthcare costs, but keeping practices strong and vibrant in today’s challenging environment is no easy task. It requires close attention to detail, planning, and execution, as well as dramatic changes in leadership style.

From a business standpoint, creating a viable business model is essential, as it provides the foundation for clinical and operational success. Staffing needs must be accurately projected, payer contracts negotiated, revenue cycle activities scrutinized from check-in through billing, and a reliable, cost-effective source identified for drug purchasing and that is just the tip of the iceberg. Management should also ensure staff is utilized at the top of their licensure, so that nurses and advanced practice providers (APPs) do what they are trained to do. This maximizes provider resources and creates full functioning offices where patients with mild complications can be seen the same day in the office rather than in the emergency department, therby improving the patient experience and reducing costs. These are fundamentals that must be attended to by a management with strong business skills and a thorough understanding of clinical operations.

Consultants are of Value in OCM Transition

To succeed in the value-based world, practices must also embrace alternative payment models. At Minnesota Oncology, where I practice, we emphasize our ability to rapidly alter payment models when interacting with payers. We are the only oncology group in our region embracing alternative payment models because we have the infrastructure and flexibility to rapidly improve our care delivery more quickly than large health systems can.

Community practices are opportune sites to implement The Center for Medicare & Medicaid Innovation’s (CMMI) Oncology Care Model and other quality-oriented initiatives. While these programs require extensive reporting, which is challenging for independents, outside consultants can help if needed. In our case, these requirements are made much more manageable through our affiliation with The US Oncology Network, which provided guidance and resources to help us meet the reporting requirements in our new payment models and also helped with payer negotiations.

Quality, Cost-Effective Care Is Critical for Success

Leadership also plays a key role in succeeding in this new environment. Oncology is radically changing, creating the need for a different type of physician and clinical leadership to drive change management. Today’s leaders must build relationships, provide feedback, and coach provider partners, requiring a great deal of emotional intelligence. We need to make sure we are training a leadership group that can effectively handle these tasks.

Making certain every patient receives the best care possible with an optimal outcome has the potential to strengthen referring physician relationships and builds a strong image within the community, helping to ensure success. Practices should strive to achieve high-quality Triple Aim focused care care designed to improve the patient experience, reduce per capita cost of care, and improve the overall quality of care on a population basis. The better we do this in a community setting, the more viable the practice becomes.

On a practical level, this involves improving quality by reducing unexplainable clinical variations, so patients with similar diseases receive the same high-quality care from all providers at all locations. Following care paths reduces variability, driving better outcomes and more predictable costs. In our case, we use treatment options based on efficacy, toxicity and cost developed by oncologists affiliated with The US Oncology Network and the National Comprehensive Cancer Network.

Team care also plays an important role in improving quality and providing a better patient experience. Each person who serves the patient from the receptionist to the APP needs to understand his/her role in providing quality care so everyone can function as part of a team. Teamwork and strong team interdependencies had not historically been part of the training of physicians. Learning methods for integrating these concepts at the point of care is something we are also focusing on at our offices. Clinical trials are also important, as they allow patients to access cutting-edge therapies close to home.

Adding in-office dispensing of oral cancer therapies fundamentally supports care delivery improvements by enhancing medication compliance oversight and providing a better patient integration with care teams. Lastly, it enhances revenue and reduces waste that occurs when a patient receives oral therapy from an outside vendor that does not have knowledge of all aspects of the patient’s care.

Advanced Technologies Support Quality Care

Proactively providing comprehensive advance care planning is of significant importance. Documenting the care patients want and find valuable throughout their treatment eliminates unwanted and ineffective end-of-life care. Having appropriate conversations early about patient preferences ultimately provides better family and patient satisfaction while lowering costs.

While certain business strategies and clinical programs are important to help practices stay independent, another key element is needed: innovative technology to support the paradigm change in care and reporting. A robust technology infrastructure enhances teamwork opportunities, gets patients to participate more in their own care, and significantly improves quality metrics gathering and reporting. For instance, using an electronic health record (EHR) designed specifically for oncology McKesson Specialty Health’s iKnowMed has greatly increased our efficiency and intra-office communication while promoting better team care. It features an integrated module to assist with chemo ordering, Clear Value Plus. Not only does it enhance order efficiency, but having this clinical decision support embedded into the system workflow ensures that we are treating patients safely and in accordance with evidence-based national guidelines. EHRs that have features like this are invaluable in documenting value-based care delivery for payers. Whichever EHR is selected, it should be capable of collecting a wealth of patient information that can be extracted easily for data analytics and reporting quality metrics.

Other advanced technologies are also important, including those that support revenue cycle management (RCM) and patient engagement. Practices today require technologies that provide a full front-to-back-end RCM capability to optimize the entire spectrum of financial performance. Patient engagement technology is also critical, as today’s tech savvy patients expect online access to their health records, the ability to manage their care online, as well as to communicate with their care team electronically. Patient portals and mobile applications with selfmanagement capabilities reduce face-to-face interaction, saving valuable staff time for more complex tasks.

As a final note, community oncologists do not have the same EHRs as hospitals, so sharing patient information and coordinating care with other providers is difficult. Consequently, community oncologists should support the development of a health information exchange, a super highway of real-time data flowing across the care continuum. This will enable highquality cost-effective coordinated care, drive optimal outcomes, eliminate duplicated services, and provide a better patient experience.

Community-based oncology practices that want to remain independent can still do so—successfully&mdash;even in today’s challenging environment. The best way to thrive in this new value-based world is to embrace alternative payment models and improve patient care while lowering costs. The more the practice is able to provide this cost-efficient, patient-centered care, the more viable the practice becomes in the value-based landscape.

Nicole Hartung, MD, is medical director of Quality for Minnesota Oncology, a practice in The US Oncology Network.

Wilde Mathews A. Health-care providers, insurers supersize. 

. September 21, 2015. http://www.wsj.com/articles/health-care-providers-insurers-supersize-1442850400.

Fitch K, Pyenson B. Site of service cost differences for Medicare patients receiving chemotherapy. Milliman Client Report. October 19, 2011. http://publications.milliman.com/ publications/health-published/pdfs/site-of-service-cost-differences.pdf.

The Moran Company. Results of analyses for chemotherapy administration utilization and chemotherapy drug utilization, 2005-2011 for Medicare fee-for-service beneficiaries. http:// www.communityoncology.org/UserFiles/Moran_Site_Shift_Study_P1.pdf. May 29, 2013.

Berwick, DM; Nolan, TW; Whittington, J. The Triple Aim: care, health and cost. 

. 2008;27(3 ):759-769. doi: 10.1377/hlthaff.27.3.759

Articles

The pace of consolidation shows no sign of slowing down, and this trend also applies to oncology, as more and more community-based oncology practices are joining large health systems. 

Nicole Hartung, MD

Articles

Oncology Practice Vitality Depends on Leadership