Blog | CMS and MedPAC Guidelines and Trends

Reducing Cancer Costs: Lessons from Leading Oncology Practices

Blog | CMS and MedPAC Guidelines and Trends

Reducing Cancer Costs: Lessons from Leading Oncology Practices

Sita Kapoor highlights seven lessons learned from early participants in the CMS Oncology Care Model about reducing cancer care costs.

As risk-based contracts become the norm for hospitals and health systems, engaging physicians in initiatives to decrease costs and optimize the health of specific patient populations is essential. Oncology is an area often targeted for expense reduction and outcomes improvement in population health management programs because of the high number of cases and exorbitant cancer care costs. 

As the second leading cause of death in the United States, cancer presents clinical and financial challenges to healthcare organizations. Cancer care costs commonly are two to six times greater than Medicare limits according to a recent analysis of Medicare billing records across more than 3,000 hospitals. And when oncology services are mismanaged, the financial impact can be substantial. 

One of the biggest challenges encountered by healthcare executives is physician hesitancy to change care delivery practices to support value-based care and risk-based payer agreements. Best practices and lessons learned can be ascertained from a unique stakeholder—oncology community group practices. 

The Centers for Medicare & Medicaid Services (CMS) Oncology Care Model was designed to drive meaningful workflow changes in support of value-based care and payment in oncology medicine. Oncology practices became key stakeholders in this multiyear journey to better manage population health and negotiate risk-based contracts with insurers for their cancer patients. Both physicians and staff members have embraced new cultures and initiatives to achieve key value-based goals: lower costs and improved outcomes. 

The following shared practices underscore the value of a solid foundation in powering sustainable and evolving population health management for oncology services. 

Practice 1: Draft a Scalable Clinical and Financial Strategy

Insurer contracting opportunities and risk-bearing terms should be fully explored and understood by all stakeholders. To the greatest extent possible, organizations should attempt to align health outcomes with profitability goals. 

Practice 2: Know Current Cancer Care Costs

Cancer specialists are focused on a singular condition. The transition to value-based payment means understanding patient treatment costs and conditions outside of the oncology domain. This step requires a more holistic view of costs and expanded access to oncology data to define each patient’s comprehensive cost of care and risk.

Practice 3: Develop a Comprehensive View of Data

Costs for care provided outside of the practice—for other chronic conditions, emergencies, and comorbidities—should be included to manage cost and quality. Physicians must understand the patient’s entire care experience to be able to make clinical decisions. To provide essential insight, the organization’s population health technology infrastructure must have the data analytics capabilities to:

  • Build a unified view of data spanning all care settings—acute and emergency care, ambulatory care, home care, and long-term care
  • Aggregate data elements to include in- and out-of-network services such as specialists, prescription fulfillment, pharmacy/laboratory, alternative medicine, and disease registries
  • Understand risk by provider, physician, facility, and contracted vendor
  • Track physician performance trends
  • Conduct deeper analytics and decision support at both the patient and organizational level by asking specific, oncology-related questions of the data

Practice 4: Focus Data Analytics to Further Segment the Population

Oncology patients have unique needs, protocols, and disease processes. Data analysis should be laser focused to address this specific patient population. Key questions that should be addressed included the following:

  • Who are the sickest oncology patients?
  • What other comorbidities exist?
  • Which patients have stage 4 breast cancer, and what is the organization’s cost to treat them per year?
  • Is each patient’s stage adequately documented in the electronic health record?
  • What are the associated costs at each stage?

This type of data combined with the comprehensive data set described above identifies patients with cancer who are at high risk or are in the next wave of patients with rising risk. From there, an organization can target specific groups for focused intervention to address frequent emergency department visitors and low quality scores. 

Practice 5: Empower Physicians with Accurate Data

The organization should share performance data, in a digestible format, with physicians in a group setting to identify care gaps, risks, cost of care, and other actionable items. However, comparing individual performance should always occur in a private setting. It can be helpful to devise different techniques to help physicians become comfortable with the data and the analytics, including starting small and increasing incrementally, to secure physician trust and buy-in. 

Physicians will need time for self-learning, self-evaluation, and self-realization. After four to six months, the organization can revisit the data with providers. The goal is to reshape physicians’ perceptions and increase their comfort with the use of data. Once physicians comprehend the value of data in transforming care, they will feel empowered and become strong advocates. They will then be more motivated to provide customized care, reduce variability, and improve outcomes.

Practice 6: Manage Cancer Care Holistically

Success under risk-based contracts includes effective management of social determinants of health for cancer patients. The most successful oncology practices have care coordinators to support specific patient population needs. For example, practices employ social workers, pharmacists, and educators who specialize in diabetes management and chronic heart failure as complications of cancer. Care coordinators document medical history, discuss treatment interventions and steps, and conduct proactive outreach with cancer patients. 

Practice 7: Sustain Momentum

Organizations should share success metrics to sustain momentum—including quality metrics, cost-of-care comparisons to local and national benchmarks, and trends in the use and overuse of resources. Oncology professionals are hungry for more specific insights to drive informed, evidenced-based, smarter cancer treatments. By implementing the best practices listed above, an oncology care provider can achieve the noble goals of value-based care and population health management: lower cancer care costs and better oncology outcomes. 

Sita Kapoor is CIO, HealthEC, Edison, N.J.

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Sita Kapoor

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