Payers and Providers Discuss Pros and Cons of Oncology Payment Reform

A general session at the Community Oncology Conference, Community Oncology 2.0, Moving Forward on Payment Reform, was a panel discussion that saw participation by 2 providers and a payer. Panelists included Bruce J. Gould, MD, president and medical director of Northwest Georgia Oncology Centers, and current president of the Community Oncology Alliance (COA); Bryan Loy, MD, MBA, vice president of Oncology, Laboratory, and Personalized Medicine, Health Guidance Organization at Humana; and Barbara McAneny, MD, chief executive officer of New Mexico Cancer Center. The panel was moderated by Ted Okon, MBA, executive director of COA.

Mr Okon began the discussion by asking the panel’s diagnosis of oncology payment reform.

Dr McAneny said it is interesting that fee-for-service (FFS) equates with private practice. “But a lot of us are dying under FFS because several of the services that we provide have no reimbursement. We need a payment model that would actually pay for what we did,” she said.

Pilots like the New Mexico Cancer Center's COME HOME project and others, she added, can help figure out where the money goes. “The current system does not promote, rather penalizes us for taking better care of our patients. The current system therefore needs a major overhaul,” said Dr McAneny.

Dr Loy provided a payer’s perspective on the question of payment reform. He said, “We are beginning to ask ourselves what problems are we beginning to solve and what can we solve? As a payer we are trying to identify mechanism that will helps cope with the high spending trend that currently exists.” Pointing out that breakthrough technologies are fueling the high cost, Dr Loy added that we need to be in the business of dealing with the most in the shortest amount of time. So sharing data and identifying variations across practices can prove a huge advantage, he said. “Outside of the practices, identifying the network of physicians that the practice uses or consults … there needs to be transparency on that front. We need to defragment the system and integrate it to improve member experience,” according to Dr Loy.

According to Dr Gould, his practice is beyond diagnostics and is in the treatment stage. “We have, over the past several years, identified where the pain points are. All our work with patients who are uninsured or underinsured, making sure patients get their prescriptions filled at the specialty pharmacy are the kind of things that need to be sorted out.” He emphasized also that oncologists need to be thoughtful about utilizing their resources. In his opinion, the best oncology payment model in the current climate is the gain-sharing model, which, he believes, aligns well with provider, patient, and payer objectives.

Mr Okon then asked the panel to comment on what’s currently working in oncology payment reform.

Dr McAneny said that the Oncology Medical Home (OMH) is working, adding that aggressive management of side effects of cancer and its treatment at a lower cost site of service is definitely advantageous. “We need to convince payers to support us on that front,” she said.

According to Dr Loy, the current system allows payers to gather information from medical laboratories, medical oncologists, and radiation oncologists, which can then be fed back into their system. There are solvable problems that we can work on, he said, but we need to understand all the information in a defined period of time.

Dr Gould agreed with Dr McAneny that OMH works well. It’s a model that provides better patient care, he said by using processes of care, like end-of-life care and by following guidelines. “The shared savings model seems to be working; it’s definitely a practice model of the future,” he added.

Finally, Mr Okon asked the panel to comment on what, in their opinion, is not working and needs to be fixed.

Dr McAneny believes that average sales price + 6% is definitely not working.

Dr Loy, on the other hand, said it was too complex a topic. “We (payers) have spent a lot of time creating value-based payment models in primary care. We need to figure how not to pay 2 parties for the same specialty care. That’s a very cumbersome process.” The other thing he said is to figure transformation of benefit design from FFS to making it more transparent.

According to Dr Gould, the most important thing is physicians should improve their performance. Unfortunately, the data needed to do that has several silos; accumulating all of this data to improve connectivity is very hard to do. Gathering this information and translating it to a clinically meaningful form is extremely challenging, he added.

Finally, Mr Okon asked the panel’s prognosis for oncology payment reform.

Dr McAneny said that it is absolutely inevitable, adding that the train has left the station and we have to make the change. One of the things physicians need to do is to manage the change—site of change differences in cost, 340B, and such.

“We need to identify the things that really need to change,” said Dr Loy. “We need to make sure we are measuring solvable problems.”

The Medicare oncology payment model is encouraging and a step in the right direction, said Dr Gould.