Community-based providers remain at the core of the oncology care delivery system. A panel moderated by Barbara McAneny, MD, Chief Executive Officer, New Mexico Oncology Hematology Consultants, Albuquerque, at the 11th Annual Summit of the Association for Value-Based Cancer Care in 2021 explored the road ahead for community practices in terms of balancing value and delivering optimal access to care for patients.
Declining Physician Fee Schedule
The session began with a discussion focused on the impact of a declining physician fee schedule on independent practices, which is occurring at the same time that hospitals are receiving a 2.5% to 3% annual increase under the Medicare Economic Index. With the advent of price transparency comes the recognition that hospital care is far more expensive than community care, stated Jeff Patton, MD, Chief Executive Officer, OneOncology, Nashville, TN, and Executive Chairman of the Board, Tennessee Oncology. “Where in this country do you have the high-quality, low-cost provider being disadvantaged by the system?” he asked. “It makes no sense.” To this end, community practices must promote the fact that the care they deliver is equal to that provided by hospitals.
On the radiation oncology side, the site neutrality provision in the Centers for Medicare & Medicaid Services (CMS) Radiation Oncology Alternative Payment Model (APM), along with price transparency, may work in favor of community practices, said Vivek Kavadi, MD, FASTRO, Chief Radiation Oncologist, US Oncology Network, Sugarland, TX. The CMS Radiation Oncology APM advances a prospective, episode-based payment methodology to address coding and payment challenges and promote value over volume of services while preserving or enhancing quality of care.
The solution is to prepare for opportunities around the corner, when properly prepared physician organizations can take advantage of a more rational healthcare system, said Edward J. Licitra, MD, PhD, Chairman and Chief Executive Officer, Astera Health Partners/Astera Cancer Care, Somerset, NJ. “Unfortunately, physician practices and physicians in general have not done what’s necessary to come together and march as a single army,” he said. “We try to create a model where physicians want to be part of the team, which allows us to have a bigger seat at the table. Coupled with our ability to continuously innovate across the entire organization, I’m hopeful this will allow us to survive long enough so that we will be able to benefit from a reorganization of the healthcare market.”
“We see the absurdity of what comes out of Washington all too often…the fee schedule cuts, the complete lack of transparency from hospitals,” said Nick Ferreyros, Director, Communications, Community Oncology Alliance, New York City. “The real message and takeaway that community oncology has figured out over the past few years is that without a strong voice, without having boots on the ground, and without getting into politics, you end up being a passive victim to the whims of politicians and these political games.”
Solutions for Community Oncology Practices
Dr McAneny wondered how community oncology can preserve its referral base in an era when referral networks (ie, primary care) are being bought by hospitals. “We created National Cancer Care Alliance as a way to allow practices to be small and nimble in their own market when they need to be small and nimble, but still have some economies of scale, and to be sizeable when it’s useful to be sizeable,” she said. “But I found that the number of single specialty med/onc practices seems to be shrinking rapidly. We need collaboration with radiation oncologists obviously, but we’ve added urologists, and [emergency medical technicians], and pulmonary doctors, and others into our practice to try to solidify that part of the market.”
Helping small practices in rural areas in OneOncology’s network become sustainable is a challenge, said Dr Patton, because commutes for clinicians can be long. He related that a physician recruiter at his institution spoke to every medical oncology fellow in the country last year, placing 70 across the network. “Scale affords you resources that you wouldn’t have as an individual practice,” he said. “We have been able to recruit physicians to practices when they join us that have been looking for somebody for 2 or 3 years.”
Mr Ferreyros said that Community Oncology Alliance reaches out to all fellowship programs across the country. “We’ve built a great relationship with them,” he said. “Pre-COVID, we would go and have dinners with the fellows, and have a local community oncologist come and talk about what life is like in independent practice.”
The discussion then turned to risk sharing and its impact on community oncology. The CMS Shared Savings Program moves the payment system away from volume and toward value and outcomes. It is an APM that promotes accountability, coordinates items and services for Medicare fee-for-service beneficiaries, and encourages investment in high-quality and efficient services.
“None of the data show that risk is working,” said Dr McAneny. To take on risk, community practices must have reserves to manage a financially bad year, but unfortunately most do not, she added.
A value-based process that has the potential to destroy the infrastructure of healthcare delivery needs to be rethought, she added. A structure to manage risk, or to switch the conversations from risk to accountability to prove that community oncology is delivering quality care is needed. “One of the challenges of community oncology going forward is figuring out how we’re going to manage risk and survive,” she said.
“Scale matters,” said Dr Patton. “Once you get big enough, you can afford stop loss insurance. Tennessee Oncology has stop loss for the oncology care model and it’s not that expensive. You underwrite your risk as opposed to having reserves. You offload and buy an insurance policy. It’s a lot easier. There are ways to take risk,” he explained.
“I am very intrigued at the idea of taking on risk,” said Dr Licitra. “At OneOncology, we’re developing a platform for how we would do that. It obviously takes the integration of lots of tools and assets, and cross-disciplinary teams to figure it out.” Taking on risk and having yourself as a comparator from year to year is difficult, he said.
“There’s a huge opportunity if we create a healthcare market, and our costs are pegged against others within that market. I think we could really do some meaningful work there,” Dr Licitra said.