Payment Reform
Enhanced Reimbursement for Oncology Services Pays for Patient-Centered Care By Wayne Kuznar
P
ayment models that align reimbursement to support treatment planning and care coordination encourage oncology care providers to adhere to cancer treatment pathways, said Jennifer Malin, MD, PhD, Staff Vice President for Clinical Strategy, Anthem, Thousand Oaks, CA, at ASCO 2015. Anthem has the Cancer Care Qual ity Program, which aligns the practice patterns of physicians through enhanced reimbursement mechanisms. The providers qualify for enhanced reimbursement by adhering to a treatment regimen that is part of an evidence-based cancer treatment pathway. “Oncology practices today provide a whole range of services for patients, and typically that has been paid for by most payers out of the margin on the drugs,” said Dr Malin. “We started this program to shift the reimbursement towards more of a value-based reimbursement, so oncologists receive $350 per member per month when they are on a pathway. It’s basically an alternate way of paying for the care coordination and treatment planning that they are already doing, but paying for it directly rather than through drug margins.” The pathways are available on the Anthem website, and include regimens for various cancers that are included in national guidelines. The pathways include 7 treatment options proved to be effective and cost-effective. “In order to receive enhanced reimbursement, the oncologist has to select
for one of our members one of those regimens that is on the pathway,” said Dr Malin. “This would last as long as their treatment regimen lasts.”
participating practices and patients registered under the program were assessed. Altogether, 616 practices registered 5538 patients in the program between
“There are a lot of different reimbursement models out there that all involve shifting away from paying for drug margins to paying for more of a monthly management fee....I think we will see more of a payment directly for the care and not have the payment tied to drugs.” —Jennifer Malin, MD, PhD
Practices register members with the Anthem Cancer Care Quality Program by entering data into a web-based platform that is operated by an Anthem subsidiary, AIM Specialty Health, and submit data on key clinical parameters, including cancer stage; pathology; biomarkers; planned treatment regimens; performance status; and height, weight, and body mass index. Overall, 10 Anthem health plan states are active in the program. An integrated database of claims captured from 6 participating commercial health plans and clinical data captured from
July 2014 and December 2014. The mean number of patients per practice was 8.7. The most common cancer types were breast (29% of all registered regimens), lung (15%), colorectal (13%), and lymphoma (10%). “The goal of the program is to improve the quality of care for our members by decreasing the unwarranted variation [in care] and getting effective treatments, but also to prove value for our members, because when there are different regimens available that are equally effective but cost dif-
ferent amounts, the pathway includes the most cost-effective regimen,” Dr Malin said. Based on chemotherapy claims for members incurred only from September 2014 through October 2014, 64% of members (N = 2989) were registered with the program. Among registered patients, pathway adherence was 63% for breast cancer, 72% for colorectal cancer, and 63% for non–small-cell lung cancer. “Our estimate through claims review prior to the program was that 40% to 50% of our patients were being treated according to pathway, and the data through the program show, for the first 3 cancers, we came out with 63% to 74%,” Dr Malin said. Most requests for therapy were delivered within 2 weeks of submission for review. Within the first month, 75% of requests for breast cancer treatment, 78% of requests for colorectal cancer treatment, and 73% of requests for lung cancer treatment were delivered. KRAS biomarkers were available for 40% of patients with colorectal cancer, and EGFR biomarkers were available for 19% of patients with lung cancer. “There are a lot of different reimbursement models out there that all involve shifting away from paying for drug margins to paying for more of a monthly management fee,” said Dr Malin. “Each one has approached it slightly different, but I think we will see more of a payment directly for the care and not have the payment tied to drugs.” n
Bundling Payments... Continued from page 32 neck cancer. “They value mapping of all processes, they have established measures of quality in place, and they have an understanding of costs,” Dr Newcomer said. “We found that they were totally integrated and ready to have discussions.” Patients are evaluated by a multidisciplinary team and are given up to 4 options, or “packages,” that include a mix of treatment modalities. Payment is based on the package, but it is impor tant to note that all 4 packages have the same profit margin. “There is no incentive to push the patient toward one or the other,” Dr Newcomer said. Overall survival will be the primary outcome measure. “I think this is mandatory for any risk contract,” he said.
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SPECIAL ISSUE
“A single payment rewards quality, because provider profits increase with fewer complications, with the elimination of unnecessary tests or procedures, and with improved coordination among specialists.” —Lee N. Newcomer, MD, MHA
UnitedHealthcare has shown that survival in patients with metastatic non–small-cell lung cancer is comparable between patients who receive treatment under an episode-based payment model and those who receive treatment under the fee-for-service model, even
though the episode-based payment model uses 34% fewer resources. Currently, 18 patients have enrolled in the head and neck cancer bundling project. “We don’t expect this to be a large-volume process,” Dr Newcomer acknowledged. “We want to set a prec-
edent to move into bigger areas.” A number of lessons have already been learned, he said. Collaboration is essential, which means working together and not being adversarial. Financial incentives help to focus attention “and bring us to the table,” and data highlight the priorities. A comparison group is critical, and this must be contemporary and case- adjusted. Survival and quality measures are “a must,” because they counterbalance the risk of undertreatment. Dr Newcomer concluded by advising oncologists to limit their risks to learn how to succeed. “Some risk is a good thing, because it focuses you,” he said, “but don’t make it too large. You are not insurance companies.” n
AUGUST 2015
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Enhanced Reimbursement for Oncology Services Pays for Patient-Centered Care By Wayne Kuznar
P
ayment models that align reimbursement to support treatment planning and care coordination encourage oncology care providers to adhere to cancer treatment pathways, said Jennifer Malin, MD, PhD, Staff Vice President for Clinical Strategy, Anthem, Thousand Oaks, CA, at ASCO 2015. Anthem has the Cancer Care Qual ity Program, which aligns the practice patterns of physicians through enhanced reimbursement mechanisms. The providers qualify for enhanced reimbursement by adhering to a treatment regimen that is part of an evidence-based cancer treatment pathway. “Oncology practices today provide a whole range of services for patients, and typically that has been paid for by most payers out of the margin on the drugs,” said Dr Malin. “We started this program to shift the reimbursement towards more of a value-based reimbursement, so oncologists receive $350 per member per month when they are on a pathway. It’s basically an alternate way of paying for the care coordination and treatment planning that they are already doing, but paying for it directly rather than through drug margins.” The pathways are available on the Anthem website, and include regimens for various cancers that are included in national guidelines. The pathways include 7 treatment options proved to be effective and cost-effective. “In order to receive enhanced reimbursement, the oncologist has to select
for one of our members one of those regimens that is on the pathway,” said Dr Malin. “This would last as long as their treatment regimen lasts.”
participating practices and patients registered under the program were assessed. Altogether, 616 practices registered 5538 patients in the program between
“There are a lot of different reimbursement models out there that all involve shifting away from paying for drug margins to paying for more of a monthly management fee....I think we will see more of a payment directly for the care and not have the payment tied to drugs.” —Jennifer Malin, MD, PhD
Practices register members with the Anthem Cancer Care Quality Program by entering data into a web-based platform that is operated by an Anthem subsidiary, AIM Specialty Health, and submit data on key clinical parameters, including cancer stage; pathology; biomarkers; planned treatment regimens; performance status; and height, weight, and body mass index. Overall, 10 Anthem health plan states are active in the program. An integrated database of claims captured from 6 participating commercial health plans and clinical data captured from
July 2014 and December 2014. The mean number of patients per practice was 8.7. The most common cancer types were breast (29% of all registered regimens), lung (15%), colorectal (13%), and lymphoma (10%). “The goal of the program is to improve the quality of care for our members by decreasing the unwarranted variation [in care] and getting effective treatments, but also to prove value for our members, because when there are different regimens available that are equally effective but cost dif-
ferent amounts, the pathway includes the most cost-effective regimen,” Dr Malin said. Based on chemotherapy claims for members incurred only from September 2014 through October 2014, 64% of members (N = 2989) were registered with the program. Among registered patients, pathway adherence was 63% for breast cancer, 72% for colorectal cancer, and 63% for non–small-cell lung cancer. “Our estimate through claims review prior to the program was that 40% to 50% of our patients were being treated according to pathway, and the data through the program show, for the first 3 cancers, we came out with 63% to 74%,” Dr Malin said. Most requests for therapy were delivered within 2 weeks of submission for review. Within the first month, 75% of requests for breast cancer treatment, 78% of requests for colorectal cancer treatment, and 73% of requests for lung cancer treatment were delivered. KRAS biomarkers were available for 40% of patients with colorectal cancer, and EGFR biomarkers were available for 19% of patients with lung cancer. “There are a lot of different reimbursement models out there that all involve shifting away from paying for drug margins to paying for more of a monthly management fee,” said Dr Malin. “Each one has approached it slightly different, but I think we will see more of a payment directly for the care and not have the payment tied to drugs.” n
Bundling Payments... Continued from page 32 neck cancer. “They value mapping of all processes, they have established measures of quality in place, and they have an understanding of costs,” Dr Newcomer said. “We found that they were totally integrated and ready to have discussions.” Patients are evaluated by a multidisciplinary team and are given up to 4 options, or “packages,” that include a mix of treatment modalities. Payment is based on the package, but it is impor tant to note that all 4 packages have the same profit margin. “There is no incentive to push the patient toward one or the other,” Dr Newcomer said. Overall survival will be the primary outcome measure. “I think this is mandatory for any risk contract,” he said.
VOL. 8
I
SPECIAL ISSUE
“A single payment rewards quality, because provider profits increase with fewer complications, with the elimination of unnecessary tests or procedures, and with improved coordination among specialists.” —Lee N. Newcomer, MD, MHA
UnitedHealthcare has shown that survival in patients with metastatic non–small-cell lung cancer is comparable between patients who receive treatment under an episode-based payment model and those who receive treatment under the fee-for-service model, even
though the episode-based payment model uses 34% fewer resources. Currently, 18 patients have enrolled in the head and neck cancer bundling project. “We don’t expect this to be a large-volume process,” Dr Newcomer acknowledged. “We want to set a prec-
edent to move into bigger areas.” A number of lessons have already been learned, he said. Collaboration is essential, which means working together and not being adversarial. Financial incentives help to focus attention “and bring us to the table,” and data highlight the priorities. A comparison group is critical, and this must be contemporary and case- adjusted. Survival and quality measures are “a must,” because they counterbalance the risk of undertreatment. Dr Newcomer concluded by advising oncologists to limit their risks to learn how to succeed. “Some risk is a good thing, because it focuses you,” he said, “but don’t make it too large. You are not insurance companies.” n
AUGUST 2015
I
www.AHDBonline.com
33
