How one practice has fared with episode-based care

A private urology practice can successfully transform itself in a relatively short time from a fee-for-service payment model for cancer care to an episode-based system, one that urologists at one community practice say provides an opportunity for enhancing quality of care.

It remains to be determined, however, whether operating under the episode-based payment model also translates into cost savings for cancer care delivery, said Jeremy Shelton, MD, MS.

In July 2016, Skyline Urology, a community urology practice in Torrance, CA, was one of two urology-predominant practices that began participation in the Centers for Medicare & Medicaid Services’ episode-based payment model targeting medical management of cancer. Known as the Oncology Care Model (OCM), the episode-based payment model was established under the Medicare Access and CHIP Reauthorization Act of 2015 with the hope of aligning payment incentives to increase quality and lower costs. It provides a per-beneficiary-per-month payment to help fund practice transformation, including enhanced patient navigation, use of data for quality improvement, and use of a certified electronic health record.

In addition, it provides performance-based payments when high-value care is delivered.

At the AUA annual meeting, Dr. Shelton presented findings from a review of Skyline Urology’s first-year experience.

“Skyline Urology, like many large urology practices, has seen the opportunity for improved quality of care in novel payment systems for several years, but despite multiple efforts was unsuccessful in finding an interested payer to partner with. With OCM from the CMS, the practice finally got the chance,” said Dr. Shelton, who was previously a Skyline Urology provider and is now at UCLA’s David Geffen School of Medicine, Los Angeles.

“It is evident from Skyline Urology’s experience that the practice transformation aim of OCM is a success. With the appropriate funding model, the practice was able to deliver components of care, like care coordination and navigation, that are typically missing in a fee-for-service environment. To date, however, the practice has not been able to achieve CMS’s goal of both improving quality of care and reducing costs. It may be that it is too early to tell or perhaps the model, which was developed primarily to target medical oncology practices, needs to be tweaked to make it successful from a cost standpoint when implemented in urology.”

During the first year of Skyline Urology’s participation in the OCM, 574 patients qualified, of whom 76% had prostate cancer, 21% had bladder cancer, and 1% had kidney cancer. In order to provide the additional services stipulated in the OCM program, the practice hired 3.5 full-time employees, including two licensed vocational nurses and 1.5 data analysts. Additionally, under the leadership of Cancer Center Directors and nurse practitioners Shirley Lee and Melanie Reed, Skyline Urology built out a data warehouse for the cancer center patients, physician staff underwent training, and the practice paid for 720 consulting hours for workflow redesign and chart abstraction.

An analysis of patient service delivery showed that the vast majority of patients (84%) had an assessment at least every 6 months for pain, depression, psychosocial needs, and as needed, end-of-life planning. Intervention in these areas was also being provided as needed.

Next: During its first year of OCM participation, Skyline Urology did not qualify for a performance-based bonusDuring its first year of OCM participation, Skyline Urology did not qualify for a performance-based bonus. Dr. Shelton noted that compared with the medical oncology practices participating in the program, the overall cost of cancer care delivered by Skyline Urology and other urology practices tends to be lower, leaving less room to create savings.

“As another component, when there is a concerted effort to improve quality of care and provide more appropriate medical care to patients, there can be a corresponding increase in cost of care delivery, which so far is what the practice has found,” he said.

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Currently, Dr. Shelton and colleagues are assessing whether Medicare spending for care of urologic cancer patients can be reduced to generate overall savings.

“We believe that the main pathways by which a urology practice can reduce Medicare spending for cancer care is by providing services aiming to reduce emergency department (ED) visits or hospitalizations and by reducing expenditures near the end of life,” said Alec Koo, MD, OCM program director at Skyline Urology.

He noted that with the aim of reducing ED visits, Skyline Urology has begun to provide better access to care outside usual office hours, tried to establish stronger relationships with primary care practices in the community, and increased contact with patients who are deemed at higher risk of going to the ED as a proactive measure to direct them toward another site of care.

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