Downstream revenue (DSR)—revenue that is not earned immediately but comes from additional patient services rendered at a later time—and value-based care—which reduces the number of interventions and pays clinicians for positive patient outcomes due to shared savings—are both excellent ways to boost revenue potential. For oncology practices, these boosts can be realized by adding three specialists: a cancer genetic counselor, a nurse navigator, and a cancer dietician.
Cancer Genetic Counselor
In a recently published study in JCO Oncology Practice, the benefits of enhanced cancer risk reduction measures for patients with hereditary predispositions to certain cancers was shown to bring in substantial DSR. Among 425 patients who met with a genetics counselor at a Texas cancer center, the DSR totaled almost $33 million after such encounters, with these patients collectively generating almost 74,000 work relative value units. In the study, the high DSR was mainly attained by identifying patients with a predisposition to hereditary breast or ovarian cancers or Lynch syndrome, but the findings can be applied to carriers of other pathogenic variants. The study investigators noted that substantial DSR was also generated by institution-naïve and other unaffected patients who opted to continue receiving care at the institution.
Nurse navigator specialists, in conjunction with cancer care navigation programs, can help reduce healthcare costs and generate additional revenue opportunities for hospitals, according to an observational study published in JAMA Oncology. The study found that use of cancer care navigation programs directly correlated with declines in healthcare use and costs, with three notable results. First, there was an improved return on investment of 1:10, which came from a reduction in costs of $781.29 per patient per quarter versus non-navigated patients, resulting in an annual cost savings of a little over $475,000 for 152 navigated patients. Second, there was a decrease in resource use, with fewer emergency department visits, hospitalizations, and intensive care unit admissions. Finally, there was increased patient activation, because barriers to care were overcome and patients were equipped to stay connected within the community. Based on their findings, the study investigators concluded that patient navigation “has the potential to reach the Triple Aim of improved health care, better health, and lower costs and significantly enhanced health care delivery in the United States as health systems transition to value-based health care.”
Nutrition is well known to play a crucial role in cancer prevention, treatment (eg, managing toxicities, improving outcomes and quality of life), and survivorship, making a registered dietitian nutritionist (RDN) a crucial member of the interdisciplinary care team. An article published by the Association of Community Cancer Centers (ACCC) makes a business case for hiring an RDN, noting that medical nutrition therapy (MNT) is an evidence-based intervention that can prevent, delay, or manage diseases and conditions, with nutrition education and counseling provided by an RDN being components of MNT that are reimbursable. The article outlines several billing considerations:
- In the outpatient setting, MNT is reimbursable as a fee-for-service, with the potential for revenue streams in value-based payment arrangements that could be allocated for an RDN to provide MNT to patients with cancer.
- Medicaid/Medicare do not automatically disqualify patients with cancer from receiving MNT. In some states, Medicaid enrollees are entitled to MNT. While Medicare Plan B excludes MNT for patients with cancer, covering only three diseases (diabetes, chronic kidney disease, kidney transplant), Medicare Advantage plans may include such coverage for patients with cancer.
- Medical necessity requests can be used to improve access to MNT when patients’ plans do not specifically include such services for cancer-related diagnoses or associated complications.
The ACCC article recommends that providers who add an RDN to their practice also build nutrition outcomes measures into their programs. By observing outcomes that are meaningful to patients, clinicians, and payers, practices can be reassured that they have made a solid return on their investment of MNT.
Leave a Reply