This document provides an overview of Archway Health Advisors' oncology care management savings model and estimate of savings for Oncology Care Practice. Archway analyzed CMS claims data to establish national, state, regional, and practice-level benchmarks. Oncology Care Practice's costs are higher than benchmarks, especially for chemotherapy and outpatient services. Archway's savings model estimates annual savings ranging from $1.3-1.6 million from reducing ER visits, avoidable hospitalizations, service duplication, and increasing chemotherapy pathway adherence through care management. Oncology Care Practice could expect $1.3 million in payments over two years and $4.3 million over five years of the OCM program.
2019 outpatient prospective payment system final rule key pointsBESLER
The 2019 Hospital Outpatient Prospective Payment System (OPPS) Final Rule has been issued and changes are on the way that can affect your organization’s Medicare reimbursement.
As part of our commitment to help protect and enhance your Medicare revenue, we’ve developed this expert analysis of the FY 2019 OPPS Final Rule to quickly give you insight into the most important changes.
BESLER remains your trusted advisor and we look forward to helping you identify areas of revenue opportunity for your facility.
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The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
2019 outpatient prospective payment system final rule key pointsBESLER
The 2019 Hospital Outpatient Prospective Payment System (OPPS) Final Rule has been issued and changes are on the way that can affect your organization’s Medicare reimbursement.
As part of our commitment to help protect and enhance your Medicare revenue, we’ve developed this expert analysis of the FY 2019 OPPS Final Rule to quickly give you insight into the most important changes.
BESLER remains your trusted advisor and we look forward to helping you identify areas of revenue opportunity for your facility.
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Author(s) and affiliation(s): Paula Lorgelly (OHE), Patricia Cubi-Molla (OHE), Mark Pennington (King's College London), Richard Norman (Curtin)
Conference/meeting: EuHea 2018
Location: Maastricht, Netherlands
Date: 13/07/2018
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
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CMS announced the Quality Payment Program (QPP) final rule in October 2017, stating how it plans to implement the clinician payment changes to QPP, mandated under the Medicare Access and CHIP Reauthorization (MACRA) act. The implementation of the MACRA act impacts different type of organizations, one such being the Accountable Care Organizations (ACOs). ACOs are evaluated for payments on the basis of quality care and the cost factors associated in achieving their quality goals. Post MACRA implementation, all clinicians will receive payments as per the MIPS (Merit based incentive payments) and Advanced APMs (Advanced alternative payment models). ACO’s can register as APM entities and are eligible to receive payments under Advanced APMs. There is a third category of APM entities which participate in Advanced APMs models but do not meet the threshold of payments and patients set by CMS. Such entities fall into a category that is straddling the line between APM and the MIPS track, called MIPS APM (partially qualifying APM participants). This document discusses about the reporting, scoring and payments for the MIPS APM entities
The Accountable Care Organization Final Rule may be a 700-page mammoth, but fear not! This presentation will provide you with the highlights you need to know about the Final Rule, including details on the ACO contract with CMS; information on ACOs and FQHCs, Rural Health Centers and Hospitals; required processes and patient-centered criteria; quality and reporting highlights; application details; and more!
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The Centers for Medicare & Medicaid Services (CMS) published the proposed payment rules on the outpatient prospective payment system (OPPS) and the Medicare physician fee schedule (PFS) on July 14 and 15, 2016. If finalized, the changes generally would be effective Jan. 1, 2017.
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The Accountable Care Organization Final Rule may be a 700-page mammoth, but fear not! This presentation will provide you with the highlights you need to know about the Final Rule, including details on the ACO contract with CMS; information on ACOs and FQHCs, Rural Health Centers and Hospitals; required processes and patient-centered criteria; quality and reporting highlights; application details; and more!
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AbbVie has acquired Stemcentrx. Learn more from the first outside investor and board member, Stuart Peterson: https://medium.com/artis-ventures/congratulations-stemcentrx-e65576762d28
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Transitioning to value based care in medical oncology is a major strategic change in any medical practice. In this presentation to Grand Rounds at the Norris Cotton Cancer Center at Dartmouth, we look at the strategic and operational considerations of making such a transition effective.
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The Alphabet Soup of Clinical Quality Measures ReportingBill Presley
CMS is transitioning to what the they call "a new and more responsive regulatory framework" for quality reporting and reimbursement. CMS goals are "…electronic health records helping physicians, clinicians, and hospitals to deliver better care, smarter spending, and healthier people". Over the next couple years, we will see a transformation of fee for service into value-based care models driven by the VBP, Quality Payment Program, MACRA, Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APM). Healthcare organizations will no longer be motivated by implementing and meeting Meaningful Use, but instead will be driven by value-based care and risk-based payment models that focus on quality outcomes for reimbursements.
In this Education Session we will review:
• How CMS is aligning clinical quality measures (CQMs) to reduce the reporting burden for healthcare organizations and providers. We will cover the vision and goals for achieving quality alignment for CMS.
• We will dive into the following CMS reporting programs and how they interact with each other: Value-Based Purchasing (VBP), Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payments (MIPS), Hospital Inpatient Quality Reporting (IQR), The Joint Commission (ORYX), Outpatient Quality Reporting (OQR), and Alternative Payment Models (APM).
Insurance reimbursement in the oncology marketsmithjgrace
New payment models, especially for those providing oncology medical billing services, have been designed to improve the value and effectiveness of medical care. For this, the Centre of Medicare and Medicaid Innovation devised a new model called the 'Oncology Care Model.' "Under the Oncology Care Model (OCM), physician practices have entered into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients.
Defining What is Value-Based Care for Patients with Relapsed/Refractory Chro...Carevive
The target audiences for these activities are hematologists, medical oncologists, pulmonologists, pathologists, physician assistants, nurse practitioners, registered nurses, oncology nurses, nurse navigators, palliative/symptom management teams who care for patients with chronic lymphocytic leukemia (CLL) and quality administrators responsible for their cancer center’s adherence to value-based care delivery models.
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The alphabet soup of clinical quality measures reporting and reimbursement 2...Bill Presley
CMS is transitioning to what the they call "a new and more responsive regulatory framework" for quality reporting and reimbursement. CMS goals are "…electronic health records helping physicians, clinicians, and hospitals to deliver better care, smarter spending, and healthier people". Over the next couple years, we will see a transformation of fee for service into value-based care models driven by the VBP, Quality Payment Program, MACRA, Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APM). Healthcare organizations will no longer be motivated by implementing and meeting Meaningful Use, but instead will be driven by value-based care and risk-based payment models that focus on quality outcomes for reimbursements.
In this Education Session we will review:
• How CMS is aligning clinical quality measures (CQMs) to reduce the reporting burden for healthcare organizations and providers. We will cover the vision and goals for achieving quality alignment for CMS.
• We will dive into the following CMS reporting programs and how they interact with each other: Value-Based Purchasing (VBP), Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payments (MIPS), Hospital Inpatient Quality Reporting (IQR), The Joint Commission (ORYX), Outpatient Quality Reporting (OQR), and Alternative Payment Models (APM).
• How the Eligible Hospital and Eligible Professional reimbursement models will change in 2017 and going forward.
• Compare and contrast the requirements for quality measure reporting and identify strategies to ensure compliance.
• The potential impact to hospital reimbursement of current and proposed programs that will affect quality reporting for hospitals and providers.
• How to improve efficiency and quality by aligning measures across initiatives.
• Where to find current information (and breaking news) on each of these Quality Initiatives.
In the past, organizations participating in quality reporting initiatives involved abstractors sifting through a small sample set of unstructured data in paper charts to then manually convert their findings to discrete reportable data. This approach is time consuming and requires extensive amount of resources from both IT and Quality staff. Aligning quality initiatives can improve efficiencies and processes, and contribute to population health management efforts, both locally and nationally.
At the conclusion of this presentation, attendees will be able to apply what they’ve learned about aligning Clinical Quality Measures across initiatives specific to their organization to improve reimbursements, reduce their reporting burden, increase efficiencies, and realize the benefits of Population Health Management.
If you are responsible for hospital quality, IT, clinical quality measure initiatives or have a vested interest in making sure your organization is aligning quality measures reporting, this informational session is a must.
The Latest Regulations, Simplified: MU, PQRS & MIPSathenahealth
Changing governmental regulations for the advancement of healthcare is more than difficult and we have simplified these changes to keep you up to date.
The CMS Innovation Center hosted a special webinar featuring Dr. Patrick Conway, CMS Deputy Administrator for Innovation and Quality and CMS Chief Medical Officer, on Monday, November 10, 2014 from 10:30am – 11:30 am ET. Dr. Conway will provided an update about the work of the CMS Innovation Center and the models being tested to improve better care for patients, better health for our communities, and lower costs through improvement for our health care system. Opportunities for questions were provided.
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Journal of applied clinical medical physics Vol 14, No 5 (2013)oncoportal.net
Journal of applied clinical medical physics Vol 14, No 5 (2013)
--
Журнал прикладной клинической медицинской физики (JACMP) публикует статьи, которые помогут клиническим медицинским физиков выполнять свои обязанности более эффективно и результативно, с большей полезностью для пациента. Журнал был основан в 2000 году, является журналом открытого доступа и публикуется дважды в месяц.
1. OCM Benchmark & Savings Report
June 17, 2015
Prepared for: Oncology Care Practice
2. TABLE OF CONTENTS
EXECUTIVE SUMMARY
I. Savings Model Overview
II. Benchmarks
A. Service Category
1. National
2. State - Massachusetts
3. Regional - Springfield, MA Hospital Referral Region
4. Practice - Oncology Care Practice
B. Cancer Type
1. Service Category Analysis
2. Benchmarks and PGP Performance
III. Savings Estimation
A. CMS Data Sample Size Analysis
B. Savings Distribution
C. Savings Model
D. Archway Oncology Care Management Savings Estimate
IV. Savings Detail
V. Endnotes
Page 2
3. EXECUTIVE SUMMARY
● $447,227 from advanced care planning
● $526,164 from chemotherapy pathway adherence
● $223,033 from ER visit reduction
● $48,151 from avoidable hospitalizations
● $155,183 from service duplication reduction
CMS
Sample Oncology Care Practice
Cancer of lymphatic and hematopoietic tissue 12 24
Cancer of male genital organs 20 96
Cancer of urinary organs 4 48
Cancer of uterus and cervix 2 14
Colorectal cancer 2 58
Other gastrointestinal cancer 4 27
Maintenance chemotherapy; radiotherapy 11 30
Cancer of breast 2 77
Cancer of bronchus; lung 8 92
Spend per OCM Episode
Cancer of lymphatic and hematopoietic tissue 51,542$
Cancer of male genital organs 9,260$
Cancer of urinary organs 18,696$
Cancer of uterus and cervix 29,869$
Colorectal cancer 51,221$
Other gastrointestinal cancer 32,181$
Maintenance chemotherapy; radiotherapy 38,945$
Cancer of breast 29,105$
Cancer of bronchus; lung 34,175$
Oncology Care Practice can expect to generate $1,317,593 in additional revenue during the first two years of OCM, and a
total of $4,305,330 over the life of the program. This estimate is based on Archway's provisional OCM episode design using
CMS 5% files that include 65 episodes for Oncology Care Practice out of an estimated 466 reported by the practice. This
annual savings estimate assumes a comprehensive redesign of oncology care and includes savings via:
The episode sample found for Oncology Care Practice was smaller than needed for significance, and we therefore blended
expenditures with regional and state benchmarks. Oncology Care Practice's episode distribution found in our CMS sample
and that provided by the practice are shown below.
Oncology Care Practice's episode profile indicates significant opportunity for savings. As shown in the estimated per episode
spend table below there exists significant spending within each cancer type and across the key areas of expected savings.
4. SAVINGS MODEL OVERVIEW
The Oncology Care Model offered by CMS requires that applicants demonstrate how participants expect to
generate savings as well as providing a credible estimate of those savings. Archway Health Advisors uses CMS
claims data integrated with documented savings pathways from previous demonstrations. This document
outlines the process Archway uses to create quantified savings estimates for OCM application financial
narratives.
Archway has gained access to the CMS claims and enrollment data for a 5% sample of Medicare beneficiaries
stratified by county. This data includes all inpatient, outpatient, skilled nursing, and professional claims for these
beneficiaries.
The OCM request for applications lays out the basic design of bundles within the demonstration and we have
filled in the details based on the design of the Bundled Payment for Care Improvement Initiative. Archway
provisional OCM episodes begin with a professional or outpatient facility claim that include a chemotherapy CPT
code and that have a cancer diagnosis code. We have limited our list of chemotherapy codes to the drugs
specifically laid out in the OCM RFA. Cancers included in the OCM model represent our best guess at the cancers
Medicare intends to includin the model. The cancers we include are lung, breast, prostate, lymphatic, uterine,
bladder, colorectal, and other gastrointestinal. All medical claims from the initiation date through 6 months after
the initiation date are included in the episode. Part D prescription drug costs are excluded both from the
identification of chemotherapy initiation and the episode cost profile.
The costs are divided into eight service categories: ER-driven, Acute Inpatient, Post-Acute, Observation Stays,
Laboratory & Radiology, Chemotherapy, Radiation Oncology, and Outpatient & Professional.
Archway's savings model uses estimates from previous studies of oncology home models and centers on five
areas. Advance care planning, ER utilization reduction, service duplication reduction, chemotherapy pathways,
and avoidable hospitalitions represent the sources of savings in our model. The impact of these areas is
estimated for each cancer type and service category. We apply these estimates of savings to our estimate of
your practice's costs based on a combination of your performance and your regions performance. The larger the
sample of episodes in your practice's performance the more the estimate is weighted toward your specific
experience.
Page 4
5. State Benchmark - Massachusetts
Figure 2. Spending by Service Category - State Benchmark
In the state of Massachusetts we identified 1,199 episodes with mean costs of $33,120. State costs are 10.4%
higher than the national benchmark. This is driven primarily by chemotherapy cost.
ER Driven Cost
4%
Acute IP Cost
6%
Radiation Oncology Cost
7%
Chemotherapy Cost
45%
PAC Cost
7%
Observation Stay Cost
2%
EI Lab & Imaging Cost
0%
Other Lab & Imaging
Cost
5%
Outpatient &
Professional Cost
24%
Page 5
6. Regional Benchmark - Springfield, MA Hospital Referral Region
Figure 3. Spending by Service Category - Regional Benchmark
Springfield, MA Hospital Referral Region has 246 episodes with an average cost of $30,713. Regional costs are
2.4% higher than the national benchmark. This is driven primarily by outpatient & professional cost.
ER Driven Cost
4%
Acute IP Cost
8%
Radiation Oncology Cost
6%
Chemotherapy Cost
42%
PAC Cost
6%
Observation Stay Cost
1%
EI Lab & Imaging Cost
0%
Other Lab & Imaging
Cost
5%
Outpatient &
Professional Cost
28%
Page 6
7. Practice Performance - Oncology Care Practice
The CMS sample identified 65 episodes with a mean cost of $28,472. Oncology Care Practice has
very high spending in the chemotherapy service category. Outpatient and professional spending is
very high relative to benchmarks.
Figure 4. - Practice OCM Spending by Service Category
ER Driven Cost
2% Acute IP Cost
7%
Radiation Oncology
Cost
6%
Chemotherapy Cost
24%
PAC Cost
5%
Observation Stay Cost
4%
EI Lab & Imaging Cost
1%
Other Lab & Imaging
Cost
5%
Outpatient &
Professional Cost
46%
Page 7
8. Archway OCM Provisional Savings Model
Advanced Care Planning 1.5-3% All Service Categories
Pathway Adherence 8-10% Chemotherapy and Radiation Oncology
ER Visit Reduction 15-25% ER Driven Cost
Avoidable Hospitalizations 2.5-5% Acute and Post Acute Services
Service Duplication Reduction 1-5% Lab, Imaging, and Diagnostic Procedures
Low Estimate Midpoint High Estimate
End of Life Planning 402,504$ 447,227$ 504,472$
Pathway Adherence 473,548$ 526,164$ 593,513$
ER Visit Reduction 200,730$ 223,033$ 251,581$
Avoidable Hospitalizations 43,336$ 48,151$ 54,314$
Service Duplication Reduction 139,665$ 155,183$ 175,046$
Total 1,259,782$ 1,399,758$ 1,578,927$
Low Estimate Midpoint High Estimate
ER Driven Cost 140,938$ 156,598$ 176,642$
Acute IP Cost 68,583$ 76,204$ 85,958$
Radiation Oncology Cost 24,913$ 27,681$ 31,225$
Chemotherapy Cost 627,571$ 697,301$ 786,556$
PAC Cost 25,988$ 28,875$ 32,571$
Obseration Stay Cost 88,165$ 97,961$ 110,500$
EI Lab & Imaging Cost 4,233$ 4,703$ 5,305$
Other Lab & Imaging Cost 50,614$ 56,238$ 63,436$
Outpatient Cost 228,777$ 254,197$ 286,734$
Total 1,259,782$ 1,399,758$ 1,578,927$
Oncology spend savings are estimated within each service category. Table 5 presents savings estimates by service
category for Oncology Care Practice.
Table 5. - Oncology Care Practice Savings Range by Service Category
Archway's provisional OCM savings model is based on recent studies of oncology medical home and care model programs.
Research indicates that savings from oncology care model redesign result from reduced ER and acute hospital visits,
advanced care planning, reduced duplication of diagnostic services, and chemotherapy pathway development and
adherence. Working with clinicians and industry experts Archway has generated the savings ranges shown in Table 3.
Table 3 - Range of Savings by Source
For Oncology Care Practice, this results in estimated annual gross savings from $1,259,782 to $1,578,927. Table 4 displays
the range of annual savings for a fully developed program from each savings source.
Table 4. - Oncology Care Practice Savings Range by Source
Page 8
9. Archway Oncology Care Management Savings Estimate
Table 6. Annual Savings
Year 1 Year 2 Year 3 Year 4 Year 5 Total
Annual Episode Volume 466 466 466 466 466 2,328
Estimated PBPM Care Model Revenue 447,360$ 447,360$ 447,360$ 447,360$ 447,360$ 2,236,800$
Historical Claims Benchmark 15,024,642$ 15,024,642$ 15,024,642$ 15,024,642$ 15,024,642$ 75,123,212$
CMS Fee (4%/2.75%) (600,986)$ (600,986)$ (413,178)$ (413,178)$ (413,178)$ (2,441,504)$
Target Price 14,423,657$ 14,423,657$ 14,611,465$ 14,611,465$ 14,611,465$ 72,681,707$
Total Spend on Chemotherapy Episodes (13,834,848)$ (13,694,872)$ (13,624,884)$ (13,610,887)$ (13,610,887)$ (68,376,377)$
Estimated OCM PBPM Payments (447,360)$ (447,360)$ (447,360)$ (447,360)$ (447,360)$ (2,236,800)$
Total Practice OCM Debits (14,282,208)$ (14,142,232)$ (14,072,244)$ (14,058,247)$ (14,058,247)$ (70,613,177)$
Net Savings Estimate 141,449$ 281,425$ 539,220$ 553,218$ 553,218$ 2,068,530$
Net Savings Rate 0.9% 1.9% 3.6% 3.7% 3.7% 2.8%
1,189,794$ 1,329,770$ 1,399,758$ 1,413,756$ 1,413,756$ -$
Net Payment to Practice 588,809$ 728,785$ 986,580$ 1,000,578$ 1,000,578$ 4,305,330$
CMS Net Cost Reduction 600,986$ 600,986$ 413,178$ 413,178$ 413,178$ 2,441,504$
In the OCM RFA CMS asks for a detailed explanation of how the practice and CMS will split any cost savings generated by program
implementation. Table 6 depicts how savings are divided over the course of the demonstration. During the first two years Oncology
Care Practice generates $422,873 in net savings. Oncology Care Practice nets $1,317,593 of which $894,720 are PBPM payments;
CMS benefits from $1,201,971 in reduced cost. During the last three years the provisional OCM model estimates $1,645,657 in net
savings and $1,342,080 in PBPM payments. Note that in the first two years, any negative gross savings result in no cost to the
The model presented here assumes a 0% growth rate over the 5 year program. Volume is based on 12 practicing physicians with 50
OCM episodes per year. Distribution of episodes by cancer type is based on Medicare SEER data.
Page 9
10. ENDNOTES
[1.]
[2.] Barkley, Ron. "Business Case for the Oncology ACO". Downloaded from CCBD, May 27, 2015.
[3.]
[4.]
Sanghavi, Darshak, Patel, Kavita, Samuels, Kate, George, Meaghan, McStay, Frank, Thoumi, Andrea, Hart, Rio, and Mark
McClellan. "Transforming Cancer Care and the Role of Payment Reform: Lessons from the New Mexico Cancer Center " The
Merkin Series on Innovation in Care Delivery. August, 2014.
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