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10 ThingsYou Need To Do To Survive in 2010 and beyond…

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AgendaTrends In Oncology Practice 2010Practice Objectives10 Things You Can DoDiscussion


Trends In Oncology Practice

1. Flat or declining reimbursement with increasing drug costs.

2. Increasing patient out-of-pocket costs for oral and injectable therapies.

3. Inefficient and unpredictable revenue cycle.4. Increasing demand for information in exchange

for payment.5. Audits, audits, and then, more audits.


Trends in Oncology Practice

6. Patient demand for more clinical information and provider face time.

7. Pressure to automate everything ASAP.8. Higher overhead with less facility revenue.9. More regulatory intervention between

pharmaceutical companies and providers.10. Trending towards hospital-physician alliances

in Oncology care and coordination of care.


Trend #1—Less Reimbursement/ Higher Drug Costs


Trend #2--Higher Patient CostsEmployers Cannot Sustain Costs…

Mean Health Insurance Costs Per Worker Hour for Employees with Access

to Coverage, 1999-2005

Source: Kaiser Family Foundation analysis based on data from the National Compensation Survey, 1999-2005, conducted by the Bureau of Labor Statistics.


Trend #3: Unpredictable/ Inefficient Revenue Cycle

Causes:2008-2009: ESAs2010: Medicare starts and stops Increasing claims intervention by private insurance

Prior authorizationsRecord requestsPost-payment denials

Claims edits that make no senseMUEsUndecipherable remittance codes

High dollar reviews


Trend #4: Data for PayOncology Intermediary StrategiesPQRIReporting for E-prescribingQOPI measuresUPMC measures


Trend #5: Audit ManiaRACsMACsCERT

99211High dollar claims

ZPICs, MICsPrivate payer auditsHealth Reform push to eliminate waste


Trend #6: Patient Thirst for Info and “Face Time”

Multiplicity of cancer web sitesSocial networkingComplexity of patient out-of-pocket schemesMany therapeutic choices for common cancer

diagnosesHealth reform has added to the frenzy. The AMA

reports that health reform questions take “up to two hours” out of the work day.


Trend #7: Pressure to Automate

The ARRA incentives to automate health records. Physicians can make the lesser of 75% of Medicare fee schedule allowed charges or $44,000 over 5 years.

E-prescribing incentives and, then, disincentives.PQRI incentives and, then, disincentives.PQRI direct EMR interfacing starting this year.Constant requests for medical record data.


Year 2011 Is First Year

2012 Is First year

2013 Is First Year

2014 Is First Year

2015 Is First Year

2011 $18,000

2012 $12,000 $18,000

2013 $8,000 $12,000 $15,000

2014 $4,000 $8,000 $12,000 $15,000

2015 $2,000 $4,000 $8,000 $12,000 0

2016 $0 $2,000 $4,000 $8,000 0

TOTAL

$44,000 $44,000 $42,000 $35,000 0

Medicare ARRA Physician Payment Maximum Incentives – Must have already implemented “certified” EHR meeting “meaningful use” criteria

to qualify.

10% more for HPSA areas


Meaningful Use Timeline

First definition of MU

(requirements)

2011Second

definition of MU (new

requirements)

2013

Preparation for MU

2009

Third definition of MU

(requirements)

2015

Penalties for not meeting

MU

>2015

First incentives for

MU

Second incentives for

MU

Final incentives for

MU

• Requirements for meeting Meaningful Use will increase over time• Incentives run 2011-2015 and penalties begin in 2016


Trend #8: Less Reimbursement; Higher Overhead

Price of branded therapeutics; ASP reimbursement

Shortage of nurses, NPPs, physicians, and lab techs. Must have incentives to retain scarce resources.

AutomationDiversificationDebt servicePossible inflation


Trend #9: Regulatory Intervention Between Docs and Pharma

It’s been proposed in the Senate (“The Sunshine Bill”) that all remuneration to physicians over $10 or cumulatively over $100 need to be reported. Some companies are doing this voluntarily.

Many cancer drug companies have Corporate Integrity Agreements with the OIG, which limit what they can do with and for cancer clinics.

Will there continue to be indigent drug support by pharma, once Health Reform kicks in around 2015?


Trend #10: Closer Relationships Between Physicians and Hospitals

340B status by 1700+ hospitals make many hospitals “inspired” to acquire cancer practices.

For-profit hospitals eyes cancer clinics for “the downstream” revenue

Accountable Care Organizations are part of health reform.

CMS also testing out “gain-sharing” arrangements for certain diagnoses.


ObjectivesWe set these objectives for our things you should do

as you need to know why you are doing what you’re doing… Provide high quality care consistent with best practices,

optimal patient care and enhanced patient/family relations and ensure information systems can reflect practice treatment patterns.

Maintain enough cash for expected operations and debt service expense.

Optimize financial counseling and back office operations for expected or better reimbursement.

Ensure capital outlays are consistent with the forecasted needs of the practice.


#1: Have A Strategic PlanMany practices “fly by the seats of their pants”. It is

necessary to PLAN for each and every year to do the best you can within the constraints of your market and means.

Know your demographics. The Medicare mix will be changing as baby boomers reach Medicare age. How will you deal?

Other aspects: Cash needs Capital needs Marketing plan Additional services


#2: Set Patient Expectations Early In Treatment

Patients need to know from the outset how your practice operates. This will prevent complaints and questions throughout their relationship with your practice.

Patients should do the following BEFORE their first visit: Fill out forms regarding their demographics and insurance

information. Sign a condition of treatment, where they commit to paying

patient portions, telling you about changes in insurance and employment status, etc.

Understand that they will pay at the time of treatment and that you will send folks to collections as necessary.

Know a list of web pages and/or telephone numbers they will need during their treatment, if they have questions.


Conditions of Treatment Gives permission to release information in order to get paid Requires patients to get referrals that are necessary. Requires patients to notify at the time of service change of

insurance. Requires patients to notify at the time of service change of

insurance. Requires patients to supply income and asset information if

they become uninsured. Allows you to access credit cards. Allows you to perform a credit check for high balances.


#3: Use Technology Not People

Use your web site to intervene between your practice and your patients. Some suggestions include:

Allow input of practice forms and agreements on your site with automated faxing and e-mailing. Examples include: demographics, insurance, conditions of treatment, patient histories, etc.

Post FAQs for patients on your web site for general questions and by diagnosis.

Post your calendar for support groups and other patient events in your practice.

Other postings that will decrease phone calls in your practice.

Provide patients access to their personal health information to minimize questions, e.g. Altos SEE MY CHART for:

Appointment scheduling Lab results and trends Prescriptions and dosing Disease info


#4: Know Your Contracts and Disseminate Info

Administrators and Directing Physicians should know the following:

Contract basis (RBRVS, Medicare allowables, charges, etc)

Contract renewal dateContract re-opener causesContract opt-out period

Front desk should have a Contract BookBack Office should have a Contract Book and

know the fee schedule for every major payer.


Make Everyone A FCHave a Contract Book at your Front DeskPictures of Insurance CardsPre-Auth, Referrals Needed With E-mails or

Telephone NumbersEmployers Who Use, if ApplicableContract Copays and DeductiblesIn-network, Out-of-NetworkContracted Rates (for billing)Contracted Pharmacies

Discharge Area with scripts, appointments, and charging.

Signs in waiting room.


#5: Get A Certified EMR If you do not have an EMR, you will soon be left in the

dust. You need to get on this right now. If you do have an EMR, it must meet these

requirements: Be able to generate e-scripts for the incentive. Be able to generate PQRI data. Be certified for ‘meaningful use’ Be able to reflect the protocols and regimens that you

use. Be web-based for instant updates.

Get after your vendor, if requirements are not met.


#6-Police Yourself Before Others Do

Have a Continuous Quality Improvement plan. This can include: E/M auditing Revenue auditing LCD/NCD checks “Incident to” auditing Monitor protocols for physician compliance.

Have a regulatory “expert” inside the practice that keeps track of everything going on nationally and locally. This person should be charged with keeping the practice informed at staff meetings.

Ensure your patient accounting systems support the kinds of reports you will need to police yourself. You must have a good practice management system to monitor what is going on with your claims!


#7: Avoid COLA RaisesWhile Oncology practices need to be competitive for

clinicians and this may prevent your avoiding raises for them BUT…

For other staff members…Think of incentive plans related to better operation

cash based on more cash per day, lower DSO, higher profit per FTE, collection of high dollar accounts, better contracts, collected cash per hour, call stats, etc.

Incentives can include non-cash rewards: Starbuck’s cards, pizza parties, PTO, work from home days, OT, etc.


#8: Be An IntermediaryPharma and payers are paying other people to care for

your patients, in terms of of gathering data and/or keeping your patient on oral drugs. Groups like:

Oncology-specific intermediariesSpecialty PharmacyDisease Management companies

This is money out of your pocket! Your negotiations with payers should include information about the services you offer such as..

Therapy management of oral and pump infused drugsParticipation in proven regimens: NCCN, UPMC, ASCO/ASHParticipation in quality initiatives such as QOPI, PQRI for common

cancers, smoking cessation


#9: Deal With Your Hospital

A diplomatic physician should be appointed as a hospital liaison, if you do not have one. Their job might be: To ascertain where positive relations may reside or areas of

common interest. To ascertain what services overlap and where competition

might cause duplication and friction. To understand whether the hospital is interested in an

outpatient acquisition—be it you or someone else. To ascertain what joint efforts you can make to better serve

cancer patients as partners. To participate in committees or task forces looking at ACOs,

gain-sharing and/or Medical Home initiatives. Bottom line: This is not a good time to tick off your hospital.


#10: Pay Your DistributorYour distributor is not a bank and they are not a lender.

They are the supplier for your patient revenue. You cannot afford the following:

C.O.D. terms, unless your Days Outstanding from Service are less than 20-25.

Interest that will put a majority of your drugs underwater.Loss of a supplier.

Therefore, if your cash flow is too low to pay the required amount, you should look at other alternatives such as:

Lines of creditA loan from physician partnersA working capital loanSending ‘underwater’ drug patients elsewhere

Biggest Reason for Failures

Cannot pay the drug distributor and go into the “Cancer Clinic Death Spiral”


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