How Clinical Quality Assessment Aligns with Fee-for-Value Care Delivery Models
By Natasha Clinton |
In a value-based care delivery system, facilitating optimal patient care in the most cost-effective manner will be a core initiative for oncology practices in 2018 and onward.
From a top-level view, delivery of high-quality, efficient, cost-effective care will be essential as reimbursement models increasingly shift from fee-for-service to fee-for-value. And on a more tactical level, practice performance data reported to the Centers for Medicare and Medicaid Services (CMS) this year under the Merit-Based Incentive Payment System will determine up to five percent positive or negative adjustments on Medicare reimbursements applied in 2020.1
Oncologists, nurses and administrators need to know how to transform their practice to high-value care delivery systems while instilling an organizational culture of quality. Accordingly, practice leaders may consider support in optimizing their patient care delivery model. An objective overview can identify practice strengths, risks and opportunities by evaluating oncology workflows, compliance with standards and approaches to ongoing quality improvement.
Preparing for Transition
Improving clinical quality in the context of value-based reimbursement won’t happen overnight. Most practices focus on the day-to-day operations that consume the time and resources needed for the long-range planning and prioritization to implement and sustain strategic changes. An example may be “quick-fix” attempts in initiatives such as optimizing care delivery through patient navigation that may fall short if they’re not operationalized to maximize efficiency and effectiveness.
In contrast, an objective practice assessment mitigates risk and identifies improvement opportunities measuring against national standards and best practices. A practice participating in the Oncology Care Model (OCM), launched by CMS in 2016 with nearly 200 physician groups and 17 payers, ties payments to performance for episodes of care surrounding cancer therapy administration. An objective clinical excellence framework that adheres to OCM practice redesign activities can move oncology practices toward:
- Providing the core functions of patient navigation
- Adhering to the Institute of Medicine’s 13-point Care Management Plan
- Giving patients 24/7 access to appropriate clinicians who, in turn, have real-time access to the practice’s medical records
- Using treatment therapies consistent with nationally recognized clinical guidelines
- Leveraging data to drive continuous quality improvement
- Incorporating certified electronic health record technology2
How a Clinical Quality Assessment Works
In practical terms, an on-site assessment applies to any activities connected to patient care delivery. It should involve a team of oncology nurse experts, including an advanced practice nurse, who have a broad range of experience and training as community oncology administrators. Ideally, these specialists will engage practice staff through guided interviews and observation of patient care delivery workflow processes — from clinical intake to infusion suite services — to evaluate patient navigation, care coordination and team-based care delivery.
The resulting Clinical Optimization Plan presented to the practice details findings of current strengths, risks and opportunities for quality improvement. The clinical plan helps the practice prioritize initiatives for the most effective outcome in patient care delivery.
Clinical Optimization Plan strengths may be apparent in areas such as dedicated staff delivering patient-centered care, coordinated care, understanding of fee-for-value reimbursement models, patient navigation, team-based care and oncology market leadership in the practice’s geographic region.
Risks would be shared when the clinical consultant identifies healthcare worker or patient safety issues. Additionally, opportunities to improve could include a formal staff training program and recommendations for standardization through policies and procedures to ensure the highest quality patient care. Recommendations may also include updating infusion policies and procedures aligned with best practice ASCO/ONS Chemotherapy Administration Safety Standards,3 utilizing clinical staff members to the top of their licenses and capabilities, and implementing/optimizing an advanced practice provider (APP) workforce. Review and recommendations for practice redesign lead to practice transformation to a value-based care delivery model.
Overall, the assessment identifies what the practice can accomplish with its current workforce operating in the most efficient manner. An example may be deployment of a telephone triage navigation service that addresses patient side effects and symptoms from treatment or other medical issues. Telephone triage navigation determines if the patient should come to the office for a same-day appointment, thereby preventing possible emergency department visits or hospitalizations.
Also among today’s industry challenges, practices are looking for solutions to the projected oncology workforce shortage and increased demands for physician time. APPs can help bridge these gaps by leading services such as patient education, same-day office visit availability, advance care planning and smoking cessation counseling services, among others.
Aside from APPs, additional differentiation opportunities may emerge through recognition in value-based care programs, such as the National Committee for Quality Assurance’s Oncology Medical Home and through participation in payment models such as the Merit-based Incentive Payment System.
Why Clinical Optimization is so Important
There will be winners and losers under Medicare’s neutral budget. Practices that demonstrate a focus on high-quality, patient-centered care will qualify for bonuses. On the other hand, inefficiency and lack of effectiveness in a practice’s care delivery model can lead to reimbursement reductions over time. Practices will thrive by being competitive and differentiating themselves in their marketplace.
The opportunity for oncology practices in 2018 is engaging in transformation to value-based delivery of high-quality and efficient care. Practices using continual quality improvement initiatives will achieve greater success in reaching the goals of high-quality care and an exceptional patient experience.
This change in care delivery is more of a marathon than a sprint, operationalized by ongoing preparation for the ever-changing future of healthcare. Clinical quality assessment provides an objective perspective for practice improvements to be effective in this healthcare environment of change.
Forward-thinking practice leaders should act now in aligning to value-based care. Doing so will ensure that their business will thrive for years to come.
1. Modernizing Medicine. 2018 MIPS Update: The 10 Changes You Should Know About. https://www.modmed.com/blog/2018-mips-update/
2. Centers for Medicare and Medicaid Services. Oncology Care Model. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-06-29.html
3. ASCO/ONS. 2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards. https://onf.ons.org/onf/44/1/2016-updated-american-society-clinical-oncologyoncology-nursing-society-chemotherapy