User login
Bundling payments for cancer care that modify payment from current fee-for-service payments to one that rewards outcomes and cost efficiency can provide significant total cost-of-care reductions, results from a recent UnitedHealthcare pilot suggest.
"This study challenges the assumption that any reduction of resources results in worse outcomes for cancer," a report on the pilot states.
But while the total cost of care in this pilot showed reductions, looking just at the cost of chemotherapy drugs revealed an unexpected increase, reported Dr. Lee Newcomer, senior vice president of oncology at UnitedHealthcare, and his associates online in the Journal of Oncology Practice (2014 July 8 [doi: 10.1200/JOP.2014.001488]).
UnitedHealthcare built the pilot around five volunteer medical groups, including Northwest Georgia Oncology of Atlanta, Ga.; Center for Cancer and Blood Disorders of Fort Worth, Tex.; Kansas University in Kansas City, Kansas; Dayton Physicians of Dayton, Ohio; West Clinic of Memphis, Tenn.; and Advanced Medical Specialties of Miami, Fla. One group dropped out after it was acquired by an academic medical center and was replaced, but the article did not identify which one dropped out.
The pilot looked at breast, colon, and lung cancer treatments. UnitedHealthcare modified the standard fee-for-service (FFS) payment in four areas. First, chemotherapy drugs were reimbursed at the average sales price with no modifier (FFS has a contracted percentage modifier). Physician hospital care, hospice management, and case management all received an episode of care payment (the standard model offers FFS for physician hospital care, FFS or nothing for hospice management, and nothing for case management). The study sites also collected clinical and outcomes data. Medical groups were free to change their preferred drug regimen at any time, and new drugs added were paid at their respective rates, but a change did not cause a change with the episodic payments.
Predicted FFS total cost for the episode cohort was $98.1 million, but the actual total medical cost was $64.8 million. The predicted FFS chemotherapy drug cost was $7.5 million, but the actual cost was $21.0 million. The study was not designed to determine the expenses that drove the differences in cost, although a subset analysis showed a statistically valid decrease in hospitalization and therapeutic radiology usage in the episode arm.
Most quality outcomes had "insufficient numbers for statistical analysis," the report notes, though lung cancer survivors "were the only evaluable subgroup, and there was no significant survival difference between the episode and registry patients. ... Overall, multiple quality measures were monitored, and none of them provided an early signal that quality of care was different than controls."
Regarding the chemotherapy drug costs, the report’s authors noted that the increased costs were "not expected," considering the fact that the episodic payment scheme included several incentives to keep drug costs down, with no payment benefit for using more expensive drugs.
The authors suggested that the study be replicated to determine its generalization, which they say is possible with the automation of many of the claims-adjudication functions that were done manually for the study. They added that the work "proves the essential concept that the cost of care for future generations can be reduced without sacrificing quality."
Three of the article’s authors, including lead author Dr. Newcomer, are employed by UnitedHealthcare and have stock ownership in the company.
I am excited and encouraged to see the article by Dr. Newcomer and his colleagues in the Journal of Oncology Practice, demonstrating a reduction in the cost of cancer care by restructuring the revenue model to doctors and practices by removing the financial incentive to prescribe chemotherapy. It is also reassuring that they are following process measures of quality as well as outcome measures of survival in the population in the bundled payment model, in addition to their comparator population. We should all seek to reduce cost appropriately, but need to be certain that we continue to provide high-quality care to give our patients the best possible outcome.
Oncology care represents a high cost of subspecialty care in the adult population, and the oncology market is growing (as the age distribution of the population changes and people are more likely to survive their cancers and undergo chronic treatments). We as practitioners need to be able to control costs and provide high-value and high-quality care. Removing financial incentives for chemotherapy prescribing is one important part of that cost control. Bundled payment models in oncology can be another potential solution to address the cost concern. However, bundled payment systems in oncology are complex, and an outlier in cost to a practice could be financially devastating to a smaller practice. In addition, United has had other bundled pilots in oncology that have not been successful.
There are other structures of cost control that seek to align incentives with providers. WellPoint aligned with AIM to pay providers a monthly management fee for utilization of preferential pathways designed by Eviti as a prior authorization system. Dr. John Sprandio and Dr. Linda Bosserman have piloted medical oncology home projects for their smaller practices with a high level of physician oversight, seeking to reduce costs and align incentives. The US Oncology Network has Innovent Oncology, a program that aligns incentives with evidence-based Value Pathways powered by the National Comprehensive Cancer Network, advance care planning, and a nursing management system. Additionally, in order to allow physicians to access transparent, evidence-based clinical content at the point of care (which has been a major limitation for any of the pathway initiatives), Clear Value Plus was developed, which is a first of its kind clinical quality and regimen support system that’s fully embedded into McKesson Specialty Health’s iKnowMed Generation 2electronic health record (EHR), and is being developed for use in other EHRs.
I think all of these initiatives represent some progress in how we consider cost control and improve or sustain quality in oncology care, but it will always be important to continue to measure both. To measure both cost and quality, these programs need to have the informatics infrastructure in place to understand all of the long-term consequences of these measures in patient outcomes. Dr. Newcomer’s innovation in this space is an important and exciting step, but we still have a long way to go.
Dr. Debra Patt serves as the principal investigator for health economics and outcomes research for retrospective trials, as well as prospective clinical trials in breast cancer, within the US Oncology Network and leads the strategic development team for her local practice. She advocates for policies that support improving cancer care for Texas Oncology. Dr. Patt also is the director of health care informatics at McKesson Specialty Health and the US Oncology Network.
I am excited and encouraged to see the article by Dr. Newcomer and his colleagues in the Journal of Oncology Practice, demonstrating a reduction in the cost of cancer care by restructuring the revenue model to doctors and practices by removing the financial incentive to prescribe chemotherapy. It is also reassuring that they are following process measures of quality as well as outcome measures of survival in the population in the bundled payment model, in addition to their comparator population. We should all seek to reduce cost appropriately, but need to be certain that we continue to provide high-quality care to give our patients the best possible outcome.
Oncology care represents a high cost of subspecialty care in the adult population, and the oncology market is growing (as the age distribution of the population changes and people are more likely to survive their cancers and undergo chronic treatments). We as practitioners need to be able to control costs and provide high-value and high-quality care. Removing financial incentives for chemotherapy prescribing is one important part of that cost control. Bundled payment models in oncology can be another potential solution to address the cost concern. However, bundled payment systems in oncology are complex, and an outlier in cost to a practice could be financially devastating to a smaller practice. In addition, United has had other bundled pilots in oncology that have not been successful.
There are other structures of cost control that seek to align incentives with providers. WellPoint aligned with AIM to pay providers a monthly management fee for utilization of preferential pathways designed by Eviti as a prior authorization system. Dr. John Sprandio and Dr. Linda Bosserman have piloted medical oncology home projects for their smaller practices with a high level of physician oversight, seeking to reduce costs and align incentives. The US Oncology Network has Innovent Oncology, a program that aligns incentives with evidence-based Value Pathways powered by the National Comprehensive Cancer Network, advance care planning, and a nursing management system. Additionally, in order to allow physicians to access transparent, evidence-based clinical content at the point of care (which has been a major limitation for any of the pathway initiatives), Clear Value Plus was developed, which is a first of its kind clinical quality and regimen support system that’s fully embedded into McKesson Specialty Health’s iKnowMed Generation 2electronic health record (EHR), and is being developed for use in other EHRs.
I think all of these initiatives represent some progress in how we consider cost control and improve or sustain quality in oncology care, but it will always be important to continue to measure both. To measure both cost and quality, these programs need to have the informatics infrastructure in place to understand all of the long-term consequences of these measures in patient outcomes. Dr. Newcomer’s innovation in this space is an important and exciting step, but we still have a long way to go.
Dr. Debra Patt serves as the principal investigator for health economics and outcomes research for retrospective trials, as well as prospective clinical trials in breast cancer, within the US Oncology Network and leads the strategic development team for her local practice. She advocates for policies that support improving cancer care for Texas Oncology. Dr. Patt also is the director of health care informatics at McKesson Specialty Health and the US Oncology Network.
I am excited and encouraged to see the article by Dr. Newcomer and his colleagues in the Journal of Oncology Practice, demonstrating a reduction in the cost of cancer care by restructuring the revenue model to doctors and practices by removing the financial incentive to prescribe chemotherapy. It is also reassuring that they are following process measures of quality as well as outcome measures of survival in the population in the bundled payment model, in addition to their comparator population. We should all seek to reduce cost appropriately, but need to be certain that we continue to provide high-quality care to give our patients the best possible outcome.
Oncology care represents a high cost of subspecialty care in the adult population, and the oncology market is growing (as the age distribution of the population changes and people are more likely to survive their cancers and undergo chronic treatments). We as practitioners need to be able to control costs and provide high-value and high-quality care. Removing financial incentives for chemotherapy prescribing is one important part of that cost control. Bundled payment models in oncology can be another potential solution to address the cost concern. However, bundled payment systems in oncology are complex, and an outlier in cost to a practice could be financially devastating to a smaller practice. In addition, United has had other bundled pilots in oncology that have not been successful.
There are other structures of cost control that seek to align incentives with providers. WellPoint aligned with AIM to pay providers a monthly management fee for utilization of preferential pathways designed by Eviti as a prior authorization system. Dr. John Sprandio and Dr. Linda Bosserman have piloted medical oncology home projects for their smaller practices with a high level of physician oversight, seeking to reduce costs and align incentives. The US Oncology Network has Innovent Oncology, a program that aligns incentives with evidence-based Value Pathways powered by the National Comprehensive Cancer Network, advance care planning, and a nursing management system. Additionally, in order to allow physicians to access transparent, evidence-based clinical content at the point of care (which has been a major limitation for any of the pathway initiatives), Clear Value Plus was developed, which is a first of its kind clinical quality and regimen support system that’s fully embedded into McKesson Specialty Health’s iKnowMed Generation 2electronic health record (EHR), and is being developed for use in other EHRs.
I think all of these initiatives represent some progress in how we consider cost control and improve or sustain quality in oncology care, but it will always be important to continue to measure both. To measure both cost and quality, these programs need to have the informatics infrastructure in place to understand all of the long-term consequences of these measures in patient outcomes. Dr. Newcomer’s innovation in this space is an important and exciting step, but we still have a long way to go.
Dr. Debra Patt serves as the principal investigator for health economics and outcomes research for retrospective trials, as well as prospective clinical trials in breast cancer, within the US Oncology Network and leads the strategic development team for her local practice. She advocates for policies that support improving cancer care for Texas Oncology. Dr. Patt also is the director of health care informatics at McKesson Specialty Health and the US Oncology Network.
Bundling payments for cancer care that modify payment from current fee-for-service payments to one that rewards outcomes and cost efficiency can provide significant total cost-of-care reductions, results from a recent UnitedHealthcare pilot suggest.
"This study challenges the assumption that any reduction of resources results in worse outcomes for cancer," a report on the pilot states.
But while the total cost of care in this pilot showed reductions, looking just at the cost of chemotherapy drugs revealed an unexpected increase, reported Dr. Lee Newcomer, senior vice president of oncology at UnitedHealthcare, and his associates online in the Journal of Oncology Practice (2014 July 8 [doi: 10.1200/JOP.2014.001488]).
UnitedHealthcare built the pilot around five volunteer medical groups, including Northwest Georgia Oncology of Atlanta, Ga.; Center for Cancer and Blood Disorders of Fort Worth, Tex.; Kansas University in Kansas City, Kansas; Dayton Physicians of Dayton, Ohio; West Clinic of Memphis, Tenn.; and Advanced Medical Specialties of Miami, Fla. One group dropped out after it was acquired by an academic medical center and was replaced, but the article did not identify which one dropped out.
The pilot looked at breast, colon, and lung cancer treatments. UnitedHealthcare modified the standard fee-for-service (FFS) payment in four areas. First, chemotherapy drugs were reimbursed at the average sales price with no modifier (FFS has a contracted percentage modifier). Physician hospital care, hospice management, and case management all received an episode of care payment (the standard model offers FFS for physician hospital care, FFS or nothing for hospice management, and nothing for case management). The study sites also collected clinical and outcomes data. Medical groups were free to change their preferred drug regimen at any time, and new drugs added were paid at their respective rates, but a change did not cause a change with the episodic payments.
Predicted FFS total cost for the episode cohort was $98.1 million, but the actual total medical cost was $64.8 million. The predicted FFS chemotherapy drug cost was $7.5 million, but the actual cost was $21.0 million. The study was not designed to determine the expenses that drove the differences in cost, although a subset analysis showed a statistically valid decrease in hospitalization and therapeutic radiology usage in the episode arm.
Most quality outcomes had "insufficient numbers for statistical analysis," the report notes, though lung cancer survivors "were the only evaluable subgroup, and there was no significant survival difference between the episode and registry patients. ... Overall, multiple quality measures were monitored, and none of them provided an early signal that quality of care was different than controls."
Regarding the chemotherapy drug costs, the report’s authors noted that the increased costs were "not expected," considering the fact that the episodic payment scheme included several incentives to keep drug costs down, with no payment benefit for using more expensive drugs.
The authors suggested that the study be replicated to determine its generalization, which they say is possible with the automation of many of the claims-adjudication functions that were done manually for the study. They added that the work "proves the essential concept that the cost of care for future generations can be reduced without sacrificing quality."
Three of the article’s authors, including lead author Dr. Newcomer, are employed by UnitedHealthcare and have stock ownership in the company.
Bundling payments for cancer care that modify payment from current fee-for-service payments to one that rewards outcomes and cost efficiency can provide significant total cost-of-care reductions, results from a recent UnitedHealthcare pilot suggest.
"This study challenges the assumption that any reduction of resources results in worse outcomes for cancer," a report on the pilot states.
But while the total cost of care in this pilot showed reductions, looking just at the cost of chemotherapy drugs revealed an unexpected increase, reported Dr. Lee Newcomer, senior vice president of oncology at UnitedHealthcare, and his associates online in the Journal of Oncology Practice (2014 July 8 [doi: 10.1200/JOP.2014.001488]).
UnitedHealthcare built the pilot around five volunteer medical groups, including Northwest Georgia Oncology of Atlanta, Ga.; Center for Cancer and Blood Disorders of Fort Worth, Tex.; Kansas University in Kansas City, Kansas; Dayton Physicians of Dayton, Ohio; West Clinic of Memphis, Tenn.; and Advanced Medical Specialties of Miami, Fla. One group dropped out after it was acquired by an academic medical center and was replaced, but the article did not identify which one dropped out.
The pilot looked at breast, colon, and lung cancer treatments. UnitedHealthcare modified the standard fee-for-service (FFS) payment in four areas. First, chemotherapy drugs were reimbursed at the average sales price with no modifier (FFS has a contracted percentage modifier). Physician hospital care, hospice management, and case management all received an episode of care payment (the standard model offers FFS for physician hospital care, FFS or nothing for hospice management, and nothing for case management). The study sites also collected clinical and outcomes data. Medical groups were free to change their preferred drug regimen at any time, and new drugs added were paid at their respective rates, but a change did not cause a change with the episodic payments.
Predicted FFS total cost for the episode cohort was $98.1 million, but the actual total medical cost was $64.8 million. The predicted FFS chemotherapy drug cost was $7.5 million, but the actual cost was $21.0 million. The study was not designed to determine the expenses that drove the differences in cost, although a subset analysis showed a statistically valid decrease in hospitalization and therapeutic radiology usage in the episode arm.
Most quality outcomes had "insufficient numbers for statistical analysis," the report notes, though lung cancer survivors "were the only evaluable subgroup, and there was no significant survival difference between the episode and registry patients. ... Overall, multiple quality measures were monitored, and none of them provided an early signal that quality of care was different than controls."
Regarding the chemotherapy drug costs, the report’s authors noted that the increased costs were "not expected," considering the fact that the episodic payment scheme included several incentives to keep drug costs down, with no payment benefit for using more expensive drugs.
The authors suggested that the study be replicated to determine its generalization, which they say is possible with the automation of many of the claims-adjudication functions that were done manually for the study. They added that the work "proves the essential concept that the cost of care for future generations can be reduced without sacrificing quality."
Three of the article’s authors, including lead author Dr. Newcomer, are employed by UnitedHealthcare and have stock ownership in the company.
FROM THE JOURNAL OF ONCOLOGY PRACTICE
Key clinical point: Bundling physician payments for cancer care does not appear to affect quality of patient care or patient outcomes.
Major finding: Total cost of cancer care was lower when portions of payment were bundled, compared with traditional fee-for-service.
Data source: The study modified four payment elements for lung, breast, and colon cancer at five volunteer community cancer settings, with cost of care and outcome measures of those receiving care under the bundled payment scheme compared to usual fee-for-service.
Disclosures: Three of the article’s authors, including lead author Dr. Newcomer, are employed by UnitedHealthcare and have stock ownership in the company.
