Adapting and Paying for Value-Based Care

Andrew L. Pecora, MD, CPE: Fee-for-service and alternative payment models will be used simultaneously for some time. We believe this is going to create confusion, and it’s going to make it difficult. When you go from one room to the next, never mind who’s the payer and what’s their plan, is this patient on an alternative payment model or are they on traditional fee-for-service? How do you see that affecting the flow of practice, and what are you thinking about that?

Brenton Fargnoli, MD: So, it’s certainly a hurdle while we’re doing this transition from fee-for-service to value-based care. And we’ve seen oncologists who are participating in alternative payment models. But even within the alternative payment models, there’s variation. You can be in a pathways-type of alternative payment model, but have five different pathways programs. Just being in value-based care alone doesn’t reduce that variation. And then, in terms of moving from fee-for-service to value-based care, there’s a sense on the physician front of the clinical impact of wanting to treat patients with the same high-level quality. But then, there’s this other component of the program requirements that can become a distraction if they are too varied and too numerous. And so, finding consensus around those, I think, are going to be very important on the clinical side. On the payer side, oncology is a big part of payers, but there’s also cardiology, orthopedics, and primary care. So, having two separate types of programs becomes a bandwidth, resource, and expertise challenge for them to be administering programs that are both fee-for-service and alternative payment models.

Rena M. Conti, PhD: I would say, from the payer side, there’s much less confusion. Both government payers and commercial payers have been paying both fee-for-service and some sort of alternative payment model—at least in other areas of medicine, if not oncology—for at least 20 years now. For providers, I think it’s a big change. Most notably, there’s going to be times where physicians are going to have to keep track of having patients that are both being paid fee-for-service and being paid in an alternative payment model at the same time. Even within patients that are being paid within an alternative payment model framework, there are going to be differences in allowable treatment regimens, even for the very similar type of cancer. I view this as having very significant practice change costs. What I mean by that is, it’s the physician who’s going to have to be a little bit more flexible about how they perceive recommended treatment protocols. But also the staff of a lot of these practices are going to have to get very good at switching from one patient to another, one type of payment model to another, in managing the set of patients that they are responsible for at a given period of time.

Andrew L. Pecora, MD, CPE: One of the ways to address that, and I know practices are doing it—I know, our large practice is, we have 120 oncologists in RCCA—is we’re standardizing approaches for all payers up front regardless of the type of payment. It’s really not practical, at scale, to change your behavior from room to room, and I think that’s one of the things. And the other is that using technology, EMR (electronic medical record), things on top of EMRs are also going to be essential. But you made a very good point, and that is that these things cost money. And in order to get a return on investment, you have to have a return on investment. From your perspective, who’s responsible for up-front funding of the transformation? Is it the government, is it the payer, is it the patient, or is it the doctor?

Rena M. Conti, PhD: There are already payment incentives in some of the government programs for transforming care systems, investing in EMRs, etc. That was part of that HITECH (The Health Information Technology for Economic and Clinical Health) Act that was passed before the ACA (Affordable Care Act). And, frankly, I think practices are going to have to foot a lot of the bill for this transformation in order to really stay sane in the middle of a lot of change. One other thing I wanted to be sure to mention is that not all physicians are going to want to be able to keep track, or be able to keep track, of all the different payment methods that their patients flowing into their practice are being covered by. And so, one of the things, I think, that practices really need to decide and then build infrastructure around, is to what extent is it the physician’s job to keep track of different payment methods and different potential treatment regimens, and to what extent is it the clinic staff’s job? That’s going to cost money, but this is the new reality.