POHMS 4th Annual Spring Conference King of Prussia, PA March 10, 2017 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 elaine.towle@asco.org No disclosures

The Ideal This Norman Rockwell image poignantly portrays the best of what medicine, and doctoring can be. And indeed, providing this kind of individualized care is what I and my colleagues went to medical school to do.

The Reality Pathways Preauthorization Denials Cost of drugs Bad debt PQRS Meaningful use Staffing Competition RAC Audits MACRA And on and on and on….. But of course, the reality of practicing medicine is quite different today. One of the most common concerns voiced by physicians and other providers who care for cancer patients is the sheer lack of time there is to actually spend on patient care.

Practice Pressures Source: ASCO Annual Practice Census 2016

Practice Pressures: Physician-owned practices Source: ASCO Annual Practice Census 2016

Administrative Burden… It’s Not Just Your Imagination March 7, 2016 Here is concrete evidence that the stresses we are seeing every day are real. And they represent real cost to our practices and the health care system.

Administrative Burden Which pathway?? Payer E B C D F G H Payer A And it isn’t just quality reporting. Apart from quality reporting and complying with multiple pathway programs, providers tell us they—or their nurses—are still spending several hours per day on the phone with preauthorization.

The Result? 2012 38% 2015 56% 48% 43% Physician-owned practices Source: ASCO Annual Practice Census 2012-2015

Community Oncology Alliance 2016 Community Oncology Practice Impact Report: Tracking the Changing Landscape of Cancer Care

Special Concern for Smaller Community Practices (1-5 Oncologists) Backbone of U.S. cancer care delivery system 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 12% Sell 10% Close Pressures from previous slide have disproportionate impact on smaller practices They are the ones contemplating closing their doors and leaving the marketplace Note: Merge, Sell, and Close were all separate options, so there may be overlap in practices reporting each category. Numbers are those reporting “very” or “somewhat likely” For census, “small” defined as 1-5 oncologists (Note: asked them to respond on the number of oncologists, so there could be other physicians at the practice) Source: ASCO Annual Practice Census 2014

Medicare Provider Reimbursement MIPS APMs Sustainable Growth Rate (SGR) 1997 2015 2017

Medicare Quality Payment Program (QPP) 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 MIPS APMs

Will It Affect Me? 1st time Part B Participant APM Qualified EXEMPT Medicare Part B (Physician Services) 1st time Part B Participant Low Volume( $30K ) or Low Patient Count (100 Patients) APM Qualified EXEMPT EXEMPT EXEMPT

How Will Medicare Reimbursement Change? The Merit Based Incentive Payment System (MIPS) Legacy Reporting Systems MIPS VBM MIPS MU PQRS Consolidates penalties Increases incentives Ranks peers nationally Reports publicly Physician Quality Reporting System (PQRS) Meaningful Use (MU) Value Based Modifier (VBM)

How Will Medicare Reimbursement Change? The Merit Based Incentive Payment System (MIPS) Legacy Reporting Systems MIPS MIPS 2017 Adds Improvement Activity First MIPS Performance Period 2018 Cost category Scored 2019 First MIPS Payment Adjustment 2016 Last Reporting Period 2018 Last Payment Adjustment Cost Advancing Care Information(ACI) Quality Improvement Activities(IA) Not included in 2017

MIPS Payment Adjustments Timeline 2016 2019 2024 2026 +/- 4% 2020 2030+ 2025 5% 7% 2021 9% 2022+ 2018 2021 Year 1 = Performance Year 2 = Analysis 2017 Year 3 = Adjustment

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 Negative 4% payment adjustment Test the Program Report: 1 quality measure or 1 Improvement Activity The required ACI measures Avoid penalties Partial MIPS Reporting Report for at least 90 days:* 1+ Quality measure or 1+ Improvement Activity More than the required ACI *consecutive days Avoid penalties; eligible for partial positive payment adjustment Full MIPS Reporting Report for at least 90 days:* Required Quality measures and Required Improvement Activities Required ACI *consecutive days Avoid penalties; eligible for full positive payment adjustment; exceptional performance bonus 2018 Full program Implementation. 2019

Pick Your Pace in 2017 Transition Year -4% Failure to Participate in QPP in 2017 results in a Negative Payment Adjustment

Preparing for 2018 Quality ACI IA Cost 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 2-4 activities Cost Calculated automatically by CMS 0% weight in MIPS 10% weight in MIPS

Pick-Your-Pace for 2017: APM Participation CMS Recognized Alternative Payment Models (APM) Advanced APM Qualifying Physicians Exemption from MIPS 5% Lump Sum Bonus APM Specific Rewards

What is an Advanced APM? Requires use of Certified EHR Qualifying Participants Advanced APM CMS Recognized Alternative Payment Models (APM) 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

Who is a Qualifying Participant? APM entities must meet thresholds for percent of Medicare Payments Received through, or Medicare Patients in Advanced APMs Partially Qualifying Participants Qualifying Participants Advanced APM CMS Recognized Alternative Payment Models (APM) Partial QPs are those that fall below the required threshold of payments and/or patients to become full QPs, but above a lower threshold set by CMS. Partial QPs may choose to participate in MIPS or not. *Beginning in 2021, other payer APMs may be considered

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 Your Logo

ASCO Offers Solutions Certification Rapid Learning Reporting Improvement Activity APM Participation Certification Quality Reporting Rapid Learning Advancing Care Information Cost Reporting Reimbursement NEW 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

Additional ASCO Support EDUCATION AND RESOURCES Check the ASCO website regularly for new tools and resources Webinars Fact Sheets Quality Improvement library (planned) www.asco.org/macra CONSULTING & ADVOCACY 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?

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

Start your practice transformation by becoming more efficient Hire (and keep) the best staff Develop a team approach that leverages physician time Maximize your use of technology Avoid work bulges Put your practice on a growth mission

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

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

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

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 New technology tools such as LeanTaas

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…”

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

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

The brave new world: six universal payment reform elements 24/7 patient access to clinician with real-time access to patient’s medical records Robust clinical measurement and management Continuous quality improvement based on clinical and financial information Patient navigation Documented care plan (containing the 13 IOM components) Treatments consistent with nationally recognized clinical guidelines

Back to Basics…. Market share Management Measurement

Market Share New patients

Management Financial Inventory Payers 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

Measurement Revenue cycle Financial/operational 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

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

Thank you for caring for people with cancer. Questions?