Bundled Payments and Other Cost-Management Approaches to Oncology Care

THE TRANSITION TO VALUE-BASED CARE

has inspired the creation of modified and novel care delivery and payment models. But how easy or difficult would it be to adopt these models when caring for patients with cancer? At the 5th annual Patient-Centered Oncology Care^® meeting, experts from the healthcare world—both providers and payers—shared their views on how bundled payments, clinical pathways, and other value-based approaches can fit into the concept of patient-centered oncology care. The discussion, “Managing Cancer Care Costs While Ensuring Adequate Outcomes and Quality of Care,” was moderated by Bruce A. Feinberg, DO, vice president and chief medical officer of Cardinal Health Specialty Solutions.

Feinberg began the discussion by asking Kim D. Eason, MEd, manager, at Horizon Blue Cross Blue Shield of New Jersey, about the assumption that bundled care models are a poor fit for cancer care. Eason believes that the bundled payment model is in fact ideal for a chronic disease like cancer. Horizon initiated bundled payments for orthopedics and then progressed to oncology, Eason said, adding that Horizon consults with physicians prior to finalizing coverage decisions for drugs and services.

Another panelist familiar with this process was Michael Ruiz de Somocurcio, MBA, vice president of payer and provider collaboration at Regional Cancer Care Associates (RCCA). He said that when the practice works with its payer partners, like Horizon and Cigna, to develop reimbursement methodologies, the resulting bundles take into account the patient experience and quality metrics based on the Oncology Care Model (OCM). The bundled payment program only entails upside risk for the medical group, he explained, because the model is still a learning experience for RCCA and the other participating providers. “Our practices are still getting their fee-for-service reimbursement, because we believe it’s important to understand how things are working,” without having an impact on the revenue going out to those practices, Eason told the audience.

According to Bhuvana Sagar, MD, national medical director, Cigna Healthcare, guidelines are key to defining value and ensuring that providers do not take advantage of the “quality floor,” which is the baseline minimum quality of care. She emphasized that these patient-centered, evidence-based guidelines and value propositions should come from groups like the National Comprehensive Cancer Network (NCCN) or the American Society of Clinical Oncology, not payers or providers.

Ruiz de Somocurcio added that Sagar and the Horizon medical team had worked with RCCA to discuss the goals of quality metric reporting to align their practices with the OCM. Eason agreed that payers like Horizon want to gather facts from clinicians instead of blindly mandating specific clinical pathways. To help reduce underutilization, she said, Horizon has added a clinical advisory committee that examines the reported data and reaches out to practices if there are patterns that could indicate “cherry picking” of data.

Sagar said that Cigna is also reluctant to dictate specific treatment pathways to practitioners. Instead, the insurer relies on the NCCN guidelines, whenever possible, to avoid the pressure of payer-dictated guidelines and the perception that payers only care about cost, not quality. “We do emphasize that we want the best outcome possible,” she said, especially if these outcomes can be achieved at a lower cost.

Shifting gears, Feinberg discussed the current state of genetic testing reimbursement with Karen E. Lewis, MS, MM, CGC, solution management director of genetic testing at AIM Specialty Health. Lewis suggested that pharmaceutical companies should consider paying for genetic testing, because it can help determine which patients will respond the best to a certain medication, so that “we can utilize our dollars a whole lot better.” However, she also cautioned that genetic testing should only be performed if the clinician can envision how the test may benefit the patient and how the results may fit into the structure of the patient’s care plan, as opposed to performing tests simply because they are available.

Feinberg stressed that patients in America generally have a “more is better” mentality—whether they seek more information from genetic testing or request alternative treatments or drugs. Sagar and Ruiz de Somocurcio challenged that assumption, saying that value-based programs should encourage more nuanced dialogue on what each patient actually wants and how to address those desires. Patients may not want more drugs and tests, Sagar said, if these services are actually making them sicker and keeping them in the hospital longer.

Panelists emphasized that payers and providers must understand their unique roles in order to provide patient-centered care. Citing the example of end-of-life conversations, Ruiz de Somocurcio said that they may be less appropriate coming from an oncologist than from a primary care physician. Similarly, payers have noted that patients respond better to hearing about payment changes from their trusted physician, as insurers are “just who pays the claims,” Eason said.

Responding to the earlier discussion on “more is better,” an audience member said that many patients actually choose less aggressive care when they discuss their goals and imperatives with their physicians. Therefore, standard cancer care should include conversations with patients and their families on their desired balance of treatment options and quality of life or financial ramifications, for instance. The panelists agreed when the audience member stated that “if we’re really going to be person-centered, we have to focus on all of those things early on.”

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