Thriving in a Value-Based Care World: Strategies for Community Oncology Practices

The healthcare industry has undergone a seismic shift since the late 1960s, moving from a fee-forservice (FFS) model to one centered on valuebased care (VBC). The paradigm shift emphasizes the quality of care, patient outcomes and cost-efficiency over the traditional volume-based approach. While this shift promises improved patient experiences and healthcare affordability, it presents unique challenges for private practices that sometimes require additional support from organizations like the American Oncology Network. Balancing the demands of delivering high-quality care with the structural pressures of VBC requires a strategic approach extending beyond the practice’s walls.

To thrive in this new landscape, private practices must actively participate in community and national VBC programs, understanding the new payment model and learning how to implement it with as minimal disruption as possible to patient care. By collaborating with other healthcare providers, payers and community organizations, practices can leverage shared resources, reduce costs and improve patient health and outcomes. Additionally, implementing VBC strategies within the practice, such as patient engagement, care coordination and data analytics, is essential to achieve long-term success and community oncology viability.

Rising healthcare costs and declining care quality spurred the development of VBC. The potential benefits of this model for improving patient care are substantial, and the larger healthcare industry has begun to move toward this approach through policy changes and payment reforms even though the traditional fee-for-service model is still used. As a result, providers are increasingly compelled to transition to VBC models to align with this evolving landscape. For example, the Centers for Medicare and Medicaid Services along with private payers have begun updating policies to center around quality and provide associated incentives to support the transition away from FFS models.

Despite the promise of VBC, many providers in the healthcare industry have been slow to adopt this model fully. A Deloitte study from 2020 revealed that the majority of providers — 97% to be exact — were still using the FFS payment model or receiving a straight salary, with 36% receiving compensation from value-based payments. Moreover, the study outlined the challenges of incorporating social determinants of health into nonclinical care decisions, with only 73% of providers considering these factors and 46% accessing relevant economic and community data for their patients.

The transition to VBC presents substantial obstacles for many private practices that cannot be overlooked and need to be addressed. Providers contemplating this shift are confronted with several challenges that can be hard to overcome. Financial risk is a primary concern, as patient outcomes can fluctuate and reimbursement is not immediate, delaying provider payment and potentially straining capacity and resources. Additionally, establishing reliable and appropriate metrics to benchmark care quality while ensuring consistent data collection can be overwhelming. The substantial investment in healthcare technology required for tracking and reporting VBC outcomes further complicates the process. Finally, reconciling the shift from FFS to VBC reimbursement models poses significant financial and administrative challenges.

However challenging the move to the new payment models is, the benefits of becoming a VBC practice are significant. The Commonwealth Fund Organization emphasized that one of the greater benefits is that providers are able to deliver the right care to their patients at the right time. Additionally, healthcare costs may decrease; patient outcomes, satisfaction and engagement may improve; and better care coordination may transpire from the increased collaboration between providers and care teams. Ultimately, providers can return to delivering patient-centric care instead of a volume-based services approach.

The transition from traditional models to VBC can be strenuous, but with the right resources and support, private practices can make the move. According to the American Medical Association, practices need to execute on key VBC elements: providing high-quality care that is safe, timely, effective, efficient, equitable and patient-centered (STEEEP). It further stresses the importance of improved patient outcomes and satisfaction, lower costs, provider and health professional well-being, and health equity.

There are four VBC payment models according to Deloitte:

• Performance-based payments.

• Bundled payments.

• Shared savings and risk.

• Capitation.

How Payers are Supporting Value-Based Care

Health insurance companies play a pivotal role in the transition to and success of VBC in hospitals and practices nationwide. As they were key players in the fee-for-service reimbursement model, they hold a similar role in VBC movements. Under the traditional FFS payment model, payers reimbursed providers for every medical care or service provided, leading to the potential overutilization of services because of the incentive's structure, and they bore the financial risk because the cost of care widely varied.

Now, payers are reimbursing providers based on quality and outcomes, delivering even bonuses and penalties based on performance. Payers emphasize patient outcomes through the importance of preventive and coordinated care as essential measurements of VBC success. Lastly, the financial risk has shifted and is now shared between payers and providers.

VBC is not a universal payment model. Payers are using both payment models for various reasons:

• Competitive pressures and market dynamics set by regulatory changes and market demands.

• Providers’ ability to participate in VBC models.

• Various payer risk tolerances.

• Inability to implement the required technology and data infrastructure.

Providers should strive to cultivate positive relationships with payers given their important role in the VBC transition. This can lead to more favorable contract negotiations, potentially higher reimbursement rates and improved practice success.

Strategies to Transition to Value-Based Care

Transitioning to a VBC model ensures that patient care remains at the forefront of the practice and care delivery model. According to Productive Edge, here are several actionable steps to help practices transition to value-based care.

Step 1: Establish a strong commitment to VBC and learn more about it.

The move to a VBC model necessitates fundamental changes within the practice, including revised payment systems, updated processes and policies and new software for tracking key metrics. It also impacts how providers and care teams approach patient care. To successfully navigate this transition, practices can begin by firmly committing to VBC and thoroughly understanding its complexities and the cultural alignment required of key internal stakeholders, physicians, nurses and other staff members. Explore resources from reputable organizations like the National Institute of Health and the Centers for Medicare & Medicaid Services. Lastly, connect with VBC experts, such as the American Oncology Network and Community Oncology Alliance, for valuable insights and guidance.

Step 2: Develop a VBC-aligned strategic business plan.

A strategic business plan originally designed for FFS must be thoroughly revised to align with the VBC model and its unique reimbursement strategies. The new plan should clearly outline practice goals, objectives and specific timeliness with the VBC rollout and other key milestones. This is a crucial roadmap, guiding practices through the transition process with actionable steps and clear deadlines.

Step 3: Communicate VBC commitment and foster adoption.

Once the commitment to VBC is made and the business plan finalized, the next step is to inform and align all stakeholders, including care teams and third-party partners. While growing pains are inevitable during the transition, embracing these challenges can strengthen the VBC commitment and ultimately benefit patient care. As a change agent, lead the way in championing this new model and care approach. Prioritize strong, transparent and concise communication to address questions and concerns from stakeholders.

Step 4: Educate staff and care teams on VBC at the practice.

A new model may present challenges for staff and care teams, and they may struggle with understanding or adopting it. Provide additional resources on VBC and update policies and procedures to support the transition and new ways of operations and patient care. Share concrete examples of how care teams can integrate VBC activities into their daily responsibilities. Storytelling can be a powerful tool for helping teams grasp new concepts.

Step 5: Leverage available health information technology, such as electronic health records (EHR) and other advanced analytics, for VBC success.

It is important to capture VBC-related data and streamline operations by investing in the right technology. This can help ease the transition and ensure key metrics are monitored and met. According to Tech Target, essential tools include:

• Health information exchange.

• Population health management tools.

• Data analytics.

• Artificial intelligence and machine learning tools.

• Price transparency technology.

A promising example of one tool is Meaningful Insights Biotech Analytics or MiBA. This cutting-edge advanced analytics company specializes in precision data for cancer research and care. MiBA offers valuable features like clinical trial identification, market insights, improved patient tracking and predictive modeling among other services.

Step 6: Invest in care coordination and a collaborative care approach.

The VBC model prioritizes patient health outcomes. Care coordination is essential to streamlining patient care across various providers and teams, ensuring a seamless experience. Investing in care coordination processes is crucial for VBC success. A dedicated care coordination team can assist patients throughout their health journey, from diagnosis to post-treatment care and support. They can also provide proactive support, such as connecting with patients between appointments and offering guidance on nutrition. As cancer peridiagnostic delivery models (primary care, accountable care organizations, clinically integrated networks) invest in care coordination, there is tremendous potential to sync care coordination services along the spectrum of the consumers' health journey.

Step 7: Realign focus on preventive and patient-centric care.

The VBC model rewards good patient health outcomes and emphasizes preventive care to reduce hospital admissions. Preventive care, including screenings, annual check-ups and immunizations, should be a routine part of patient care — no matter the specialty. Providers should advocate for preventive care and ensure patients are actively participating. This is another example of how care coordination teams can support patients and ensure they receive necessary preventive services.

Step 8: Identify and measure robust VBC performance metrics.

Measuring success in VBC requires tracking appropriate metrics for provider evaluation and payer reimbursement. Key quality and outcome metrics include:

• Preventable infections and other disease rates.

• Patient readmission rates.

• Patient satisfaction scores.

• Chronic disease management scores.

• Cancer screening rates.

• Access to care, including time to doctor/appointment and time to treatment.

Cost metrics, such as total care costs, are also important to track. When selecting metrics, focus on categories related to effectiveness, efficiency, timeliness, safety, patient focus and equitability.

Step 9: Establish a solid risk management strategy.

Transitioning to VBC introduces financial risks that require a robust risk management strategy. Key components of this strategy include the following sections:

• Risk analysis: Identify, assess and then prioritize potential financial risks, such as coding errors, delayed payments and improper billing.

• Risk mitigation: Negotiate risk-sharing contracts with payers, purchase insurance to help protect the practice and provider, and develop a cash flow management plan.

• Financial management: Create a doable contingency plan and leverage financial modeling tools.

• Compliance: Implement strong compliance programs and internal processes to ensure adherence to VBC requirements.

Step 10: Embrace continuous improvement to improve VBC at the practice.

With a solid business plan and strategy, practices must continuously evaluate their VBC performance to ensure they are properly reimbursed. Leverage data reports and tools to assess progress against VBC requirements. Implement continuous quality improvement (CQI) plans, such as the popular Plan-Do-Check-Act, Baldrige Criteria and Six Sigma techniques, to highlight issues, develop solutions and measure results.

As a reminder, practices’ success in VBC depends on several factors: strong leadership, effective team collaboration across specialties and departments, leveraging appropriate technology tools to measure data, and a commitment to continuous learning about the VBC models and their implementation. 