The Illusion of Control: Challenges and Opportunities

Dawn Holcombe, MBA, FACMPE, ACHE
Editor-in-Chief
President, DGH Consulting, South Windsor, CT

In the best of times, managing an oncology practice is an adventure. Every day the doors to the practice open, and the physicians and staff greet, support, and empower the patients who come in for guidance, diagnosis, and treatment. In the past 10 years, oncology practices have experienced practice consolidation, acquisition, restrictions on prescribing and dispensing, rising patient financial toxicity, a push toward “value-based” and performance-based care, and now, a pandemic. Through it all, the physicians and staff of the oncology center (private or hospital-based) have tried diligently to stay focused on providing the care their patients need. However, is that enough? Are we at the tipping point where the cancer center may be on the verge of losing control of their patients, treatment choices, and the autonomy of their specialty?

Existing Loss of Control Over Patients and Treatments

For many years, increasing mergers and acquisitions between payers and specialty pharmacies have made contracting for access to patients an essential aspect of medical practice life. A cancer practice may be excluded from preferred status or inclusion in a specific provider network by health plans and medical benefit managers for a variety of reasons (competition, profiling, arbitrary criteria or limitations). Even when a cancer center is part of a treating provider network, approval for that center to treat any given patient may be affected by white-bagging or other preferred formulary and vendor decisions by payers.

Cancer centers are engaging in individual projects and contracts with Medicare (eg, the Oncology Care Model Program) and commercial payers (eg, the Aetna Medical Home Program) in an effort to prove their value and maintain critical market share and positioning. But, is that going to be enough? Preferred networks and the influence of those who control primary care and patient referrals for cancer care can greatly shift the utilization of a cancer center in an instant.

Emerging Changes in Control Over Cancer Care Options

Employers are increasingly looking for ways to exert more direct oversight of their healthcare costs, knowing that continued premium and employee cost share cannot continue to escalate. State governments, which often are among the largest employers of their state, are mounting new initiatives to reduce their costs of healthcare. In September 2019, the state of Connecticut announced an intent to alter the market dynamic as an employer by contracting directly with local or national providers and diverting care (through pricing and employee incentives) for certain medical procedures to those providers who meet defined quality goals and cost reduction benchmarks.1 Although cancer is not in the first wave of targets, it is important to note that this state, acting as an employer, has asserted very plainly that it intends to put Connecticut providers into direct competition with each other so that the state can achieve savings. Primary care will be an important focus as a gatekeeper for such direct contracting, and cancer centers will be well advised to aggressively build strategic relationships with participating primary care providers now before the opportunity is lost.

Cancer as a specialty relies heavily on referrals—from primary care physicians, surgeons, urologists, radiologists, and others. Those referrers themselves may be part of larger networks and groups that are contracting to provide services under risk and capitation models that have not even yet considered oncology as a target. If practices do not carefully watch their local markets and build their own ability to track similar risk management perspectives analytics and join the discussion, they will lose control of the conversation, and possibly their patients.

What Can Oncology Practices Do Now?

How can cancer centers retain control? Sit down and talk to those referrers who are living with capitated and performance-based contracts in your local market. One primary care network with whom I recently spoke shared that they receive full patient claims data from the major payers and employers with whom they are capitated. Some of the analytics they run are on the physicians who care for their capitated members downstream, even if those specialties are not yet specifically contracted for care. They have already ranked and evaluated those physicians for cost and care management—without any further information than claims data. It was an eye-opener for me to hear that cancer centers that I respect and know to be of high value were not among their internal higher tier rankings. Direct conversations between cancer centers and these referrers about quality objectives, management of patients with complex cancers and comorbidities, and the alignment of goals and focus should be able to change that situation and avoid loss of patients when the primary care group looks for ways to reduce costs under their global capitation contracts.

Sometimes One Just Cannot do It Alone

Physician-managed clinically integrated networks (CINs) are a popular option that multiple independent healthcare providers (private practice and hospitals) use to join forces around quality-of-care measures and allow for value-based contracting options. There are significant federal regulations to consider to avoid potential legal or fraud challenges, but a well-designed CIN strategy can provide cancer care specialists to align to have a seat at the table for contracting and for inserting objectives for actionable value-based cancer care. CINs are often overlooked in the federal and national focus in accountable care organizations or integrated delivery systems but are emerging rapidly. Approximately 500 CINs are assumed to exist in the United States.

One example of a CIN was developed by the Pennsylvania Medical Society in 2016. Although not oncology-based, it did become a statewide network for independent physician practices caring for hundreds of thousands of covered lives. This Pennsylvania Clinical Network identified 5 key success factors related to (1) physician-led governance, (2) enabling physician participation at all levels, (3) patient centeredness that focuses on the patient experience of care, (4) aggregation of data resources through a shared population health platform, and (5) the ability to work with other networks to enhance rather than dilute the quality of care in the local market without losing the importance of a strong physician-led CIN.2-4

Cancer practices may be doing a wonderful job managing the care and expectations of their patients today, but there are many forces at work that may swiftly exert control over how many and which patients are allowed to go to a wonderful practice. Some of those factors and changes may be able to be mitigated by deliberate conversations to help the cancer center better understand the perspective and decisions already being made, and those which are likely to drive healthcare delivery in that market in the near future. Aligning (not merging) with other providers along the patient cancer journey, and even other cancer providers under a CIN structure, may prove to be an advantage for value-based contracting and retention of patient care.


References

  1. Lembo K. Lembo puts health insurance market on notice with new medical RFP that redefines health care dynamic. September 26, 2019. www.osc.ct.gov/public/pressrl/2019/StateHealthPlanRFPPreparesforNewDynamic.pdf. Accessed July 16, 2020.
  2. McManamon K, Sidorov J. Clinical integrated networks: the best kept secret in healthcare. September 2019. www.pennsylvaniacin.com/wp-content/uploads/2019/10/Populaton-Health-News-Sept-2019.pdf. Accessed July 16, 2020.
  3. Damore JF, Malcoun T. 3 strategies for clinically integrated networks to achieve financial success. June 11, 2019. www.beckershospitalreview.com/strategy/3-strategies-for-clinically-integrated-networks-to-achieve-financial-success.html. Accessed July 16, 2020.
  4. Rowe MR, Evander BC. Clinically integrated networks can be a “win-win.” October 10, 2019. www.beckershospitalreview.com/strategy/3-strategies-for-clinically-integrated-networks-to-achieve-financial-success.html. Accessed July 16, 2020.

Related Articles

Subscribe to
Oncology Practice Management

Stay up to date with oncology news & updates by subscribing to recieve the free OPM print publications or weekly e‑Newsletter.

I'd like to recieve: