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Chantel Hopper
by Chantel Hopper

Why Now Is the Time to Implement a New Reimbursement Program

Is your practice fully leveraging reimbursement programs to generate new revenue streams?

Community oncology practices may see up to a 25% earnings decline in 2023 due in part to the sunset of the Oncology Care Model (OCM), a value-based care program created by CMS and now succeeded by the Enhancing Oncology Model (EOM). There are several key challenges associated with this earnings shift including regulatory changes to drug revenue, increasing costs, and higher standards for outcome-based care. And to add to the complexity, EOM doesn’t start until July 2023, meaning many practices were left with a one-year gap to shoulder patient-care investments and operations with limited or no reimbursement.

The EOM also restricts patient eligibility to seven cancer types, while reducing MEOS payments by around 50% and mandating downside risk. These limitations not only reduce revenue streams for the practice but also further restrict patient eligibility. Regardless of EOM participation, practice leaders are asking the same question—how do we generate new revenue to deliver the highest quality care for all patients?

Over the years, CMS has continued to invest in Principal and Chronic Care Management (PCM/CCM), recognizing both as critical programs in contributing to improved patient care and outcomes. Each program consists of CPT codes allowing practices to receive reimbursement for the proactive, remote care of patients with one or multiple chronic diseases. This signals the belief that actively managing patients' chronic conditions early and often can reduce overall healthcare costs, and improve outcomes, down the line. Since OCM ended, more and more oncology practices are enrolling patients in these programs to create new revenue streams.

Many practices don’t realize that under these programs, they can bill for remote patient care activities that are likely already underway. In fact, Canopy customer data shows that ~40% of reimbursed CCM/PCM care time was for activities care teams perform on a daily basis—triaging inbound symptom calls, managing scheduling appointments, Rx refills, etc. With CCM/PCM, these essential, remote patient care activities are now reimbursable.

Seeing Fast Returns from CCM/PCM Implementation

Highlands Oncology, a nationally-recognized, multispecialty practice in northwest Arkansas, was an early adopter of CCM and PCM. Jennifer Graham, Value-Based Care Manager, realized that CCM would offer the practice a way to continue delivering high-quality, proactive care activities they put in place under OCM. With Canopy’s Program Management Module, Jennifer was able to quickly identify and implement CCM and saw significant returns in just 10 weeks.

273 new patients identified and enrolled

$21k in monthly billable care time

$2MM annual revenue projection

With Canopy, Highlands quickly identified patients that met eligibility criteria, leveraged end-to-end program workflow management for activities such as consent and enrollment, and automatically captured all cross-functional time spent on billable patient care activities.

Doing More With Less

Practices may also be intimidated by the idea of operationalizing workflows and allocating staff to support new quality programs. With the right technology partner, implementing one program is not only feasible, but many practices find they can run multiple programs in parallel and maximize impact across the entire patient population. When implementing a new solution, working with a vendor that decreases your practice’s workload and doesn’t require hiring a whole new team is critical. Only 8 months after rolling out Canopy's Program Management solution, one customer enrolled over 800 patients in PCM and CCM, generating almost $150k in revenue and all without hiring additional staff. Another practice with eight providers tripled their PCM enrollment in just one month without adding additional staff, resulting in a 5x ROI.

Amy Ellis, Chief Operations Officer of Northwest Medical Specialties, realized they would need to accommodate for the changes in value-based care programs or potentially lose practice revenue. In response, Canopy built a Program Management module within three short months that today enables practices to quickly identify and enroll patients that meet eligibility criteria, manage end-to-end care plan activities, and confidently bill for precisely-tracked care time.

“Canopy recognized that need and pivoted some of the innovations that were happening in other components of the product to build a Program Management solution that could support practices with CCM/PCM. That's a perfect example of an aligned vision and understanding.”

—Amy Ellis, Chief Operating Officer, Northwest Medical Specialties

With Canopy’s Intelligent Care Platform and Program Management module, staff can spend more time on patient care with purpose-built task management and remote triage tools—including a clinically-validated ePROs solution for remote symptom monitoring—all while generating new revenue.

Maximizing Value with a Multimodal Approach

With the right tools, practices can find and run a value-based program for each patient. With multiple programs available, practices are more incentivized than ever to deliver patient-centric care to their entire patient population, and Canopy enables practices to deploy programs like CCM, PCM, and EOM in parallel to maximize reimbursement.

“There are differentials in our patient population, so we can run CCM, PCM, and other models using similar processes and the same staff we put in place for OCM. We started with CCM and have seen significant returns in a short period.”

—Jeff Hunnicutt, CEO, Highlands Oncology

Canopy’s enhanced analytics features also allow practices to utilize metrics to inform meaningful change by tracking call volumes, time spent on care calls, ePROs enrollment, quality metrics, and more. Practices can more precisely report on care time and billing codes with an auditable log.

In conclusion, while community oncology faces significant financial challenges, there are quality programs that can help practices generate new reimbursement streams for high-quality patient care. With the help of the right technology partner, practices can successfully operationalize these programs—whether one or multiple— with little additional investment, rapidly achieve returns, and maximize value for patients and care teams alike.

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Ready to see fast returns for your practice from value-based care programs? Request a consultation to learn how our platform can help your practice maximize value.