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Value-based care: An evolution, not a revolution

By Mike Fazio, Director, Value-Based Care, Specialty Solutions

Value-based care – the concept of delivering coordinated care that enables better patient outcomes and better experiences at a reduced cost – is one the most significant topics in healthcare today.

While the phrase value-based care is seemingly everywhere, there are fewer clear-cut explanations of what the concept means for both patients and clinicians. For patients, value-based care involves an entire ecosystem of clinicians across primary and specialty care working together to help keep patients healthy and out of the hospital. This is especially relevant for Medicare beneficiaries ages 65 and older who are likely managing one or more chronic condition. For providers, value-based care is about moving away from being compensated for care volume (known as fee-for-service) and toward care value. Importantly, value-based care introduces the concept of clinician financial accountability for the quality of care they deliver.

How we got here
The passage of the Affordable Care Act in 2010 codified value-based reimbursement as we understand it today. The Affordable Care Act established the Center for Medicare and Medicaid Innovation (CMMI), pushing forward America’s quest to improve healthcare quality and reduce costs. Between 2010 and today, CMMI has launched multiple value-based care pilot models. These models include Accountable Care Organizations (ACOs), the Bundled Payments for Care Improvement Advanced (BPCI Advanced) program, the Oncology Care Model (OCM) and the Enhancing Oncology Model (EOM).

Today the race is on to adopt value-based care, as the Centers for Medicare & Medicaid Services (CMS) aims to have all Medicare beneficiaries in accountable care relationships by 2030.

Community oncology’s value-based future: more than a model
Though it takes the entire healthcare ecosystem to deliver value-based care, specialists play a significant role in its overall success. This is particularly relevant in oncology and for community-based oncology practices that deliver most of the country’s cancer care. These practices also predominantly see older Americans enrolled in Medicare or Medicare Advantage plans. In value-based care arrangements community oncology practices are seen as key change agents, leading care planning and care coordination with other clinicians who provide patient care across multiple care settings.

Over the last several years, value-based care conversations in oncology have centered around several value-based reimbursement pilots including the Oncology Care Model that ended in 2022 and the Enhancing Oncology Model that began in 2023. The transition from the Oncology Care Model to the Enhancing Oncology Model was met with much criticism and debate among oncologists, resulting in low participation. One of the chief complaints of the Enhancing Oncology Model was its requirement that community oncology practices assume unprecedented financial risk as they assimilated to an entirely new value-based care delivery model.

Given that 2030 is just around the corner, the value-based care future in community oncology is coming quickly and it’s so much more than a model. This is an evolution, not a revolution, and community practices are already doing so much of the care coordination required in value-based care. Their next step is to leverage their foundational work by bringing it into the larger value-based care ecosystem and into Accountable Care Organizations (ACOs).

The path forward: Forming value-based specialty partnerships
There’s no doubt that value-based care is here in oncology. However, as with any major change, practices need support getting started and taking the right strategic steps to accomplish everyone’s goal of delivering better patient outcomes while reducing costs. Just as one would need a map for a road trip, community oncology practices can benefit from a strategic roadmap and support as they embark on their value-based care journey.

The path to value-based care success for community oncology practices begins and ends with practices positioning themselves as a high-quality partner to ACOs. As CMS moves toward its goal of having all Medicare beneficiaries in accountable care relationships by 2030, the organization wants primary and specialty care to be exceptionally coordinated. Uniting primary and specialty care under one value-based umbrella creates significant opportunity for community oncology practices to demonstrate their value to their local market ACOs with the eventual goal of engaging in partnership discussions.

Demonstrating value to ACOs should begin by looking at available quality and cost data. Community oncology practices can review their own quality and cost data from sources such as the CMS Merit-Based Incentive Payment System (MIPS) as well as performance benchmarking data based on Medicare and commercial claims. Additionally, summarizing biosimilar implementation and demonstrating end-of-life care processes and palliative care use are also helpful steps to take to get an outside-in perspective.

The next step for a community oncology practice to position itself as a high-quality partner is to demonstrate how they are implementing care management programs (principal care management, chronic care management, transitional care management). Since these care management approaches are core tenets of value-based care delivery, it will be significant for practices to document and showcase their own approaches to demonstrate their engagement and support. This will convey willingness and readiness to collaborate with ACOs and payers in their market on value-based partnership models.

While pilot value-based care models in oncology will come and go, value-based care is here to stay. At Cardinal Health we are committed to helping independent community oncology practices navigate value-based care and seek ways to deliver high-quality, coordinated cancer care. Cardinal Health offers tailored, integrated solutions to help practices improve patient care, reduce administrative burden and maximize financial performance. Embracing the evolution and charting and following a strategic roadmap to arrive at value-based care delivery keeps us all moving forward with the patient at the center.

Fazio is an industry authority with first-hand experience in value-based care payment models, risk-based arrangements, managed care contracting and payer-provider relationships. As Cardinal Health’s National Director of Value Based Care Services, Specialty Solutions, he supports customers with successful implementation and operation of value-based care programs by offering consulting services and technology products. Most recently, Fazio served as SVP of Client Services at value-based care services company Archway Health (now part of Coverys) where he formed partnerships with health systems and physician groups across the country to improve health outcomes while achieving cost savings.

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