1. 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

2. Elaine L. Towle, CMPE Division Director, Analysis & Consulting Services No disclosures

3. 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.

4. 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.

5. Practice Pressures
Source: ASCO Annual Practice Census 2016

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

7. 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.

8. 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.

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

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

11. 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

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

15. 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

16. 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

17. 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)

18. 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

19. 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

20. 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

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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. ASCO’s Top Ten List for MACRA Implementation in 2017
Pick Your Pace in 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.

29. 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.

30. 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

31. 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

32. Additional ASCO Support
EDUCATION AND RESOURCES
Check the ASCO website regularly for new tools and resources
Webinars
Fact Sheets
Quality Improvement library (planned)
CONSULTING & ADVOCACY
Practice Transformation
Readiness for Alternative Payment Models
Filing Extensive Comments

33. For more QPP information….

34. So…. what do I do now?

35. 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, May/June 2013

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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…”

42. 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

43. 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

44. 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

45. Back to Basics….
Market share
Management
Measurement

46. Market Share
New patients

47. 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

48. 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

49. 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

50. Thank you for caring for people with cancer.
Questions?