Alternative Payment Models and Quality in Lung Cancer

John Fox, MD, MHA: I once thought that cancer, or oncology, would be the last bastion for fee-for-service payments because of the incredible complexity of cancer, the number of the different types of cancer, and the different stages of cancer. But we’ve moved into an era now where CMMI, the Center for Medicare & Medicaid Innovation, has put together an Oncology Care Model (OCM) where they’re asking providers to go at risk for the total cost of care—not just cancer care, but all cancer care or all costs for patients who have cancer.

For providers who are at risk for the total cost of care who are in the OCM, there is the potential that providers could withhold appropriate therapy, or give substandard therapy, for the sake of maximizing their revenue. So now, instead of a revenue center, patients have become a cost center. It’s critically important to have quality metrics built into these programs to ensure that we don’t sacrifice patient outcomes, whether it be quality of life or longevity of life, in these alternative payment models.

There have been a number of studies that have been published that have shown, for example, that pathways can reduce the total cost of cancer care. About 75% of that savings is due to the drugs themselves, but there are many other ways of reducing the cost of cancer care, such as through avoidable emergency room visits, avoidable hospitalizations through same-day access to healthcare services, and nurse triage programs that steer the patient to the office instead of to the emergency room or the hospital.

Another example is through palliative care programs. Dr Janet Temel published (from Massachusetts General Hospital, 7 years ago) that adding palliative care to non—small cell lung cancer treatment not only improved longevity of life by, on average 2.5months, but also improved quality of life and reduced depression. I’d say that if palliative care were a drug, everybody in the country would be on that drug. So, I think the point is that palliative care and advanced care planning are built into quality metrics. They’re built into the OCM 13-point care plan, and again, they’re intended to ensure that the patients’ preferences are taken into account and that they aren’t pushed aside out of financial interests on the part of the provider.

In the OCM, from CMS (Centers for Medicare & Medicaid Services), providers are at risk for the total cost of care in patients who have non—small cell lung cancer. There are a lot of challenges for a health plan like ours (that’s also participated in an OCM) to do a total-cost-of-care model. So, for common types of cancer (for breast, lung, colon), we do have incentives for providers, but they’re more centered around ensuring that patients have advanced care planning, they’re involved in palliative care, and that we reduce the costs associated with avoidable emergency room visits and hospitalizations.

There can be multiple types of incentives. They don’t all have to be around the total cost of care, and they don’t have to be around drug selection. As I said, there are many ways of reducing the cost of care. We’ve chosen to focus on avoidable hospitalizations and emergency room visits, and those services that have been shown to reduce the cost of care, including palliative care and advanced care planning.