Defining the Boundaries of Oncology Management

Dawn Holcombe, MBA, FACMPE, ACHE

August 2014, Vol 4, No 5 - From the Editor

Managing oncology is a challenge from many perspectives. Physicians balance a patient’s medical condition with his or her medical benefit structure as well as physical, mental, social, and financial situation, and strive for the best possible solution. When considering reimbursement models, there is a fine line between a physician choosing the best option based on a patient’s needs versus choosing one based on a fixed menu of care choices determined by a payer.

WellPoint Cancer Care Quality Program Treatment Pathways is a reimbursement model being rolled out in 6 states this year with the intent to cover the full WellPoint network by the middle of 2015; it is also implementing the program through its subsidiary, AIM Specialty Health. The program is initially offering specific approved treatment regimens for breast, colorectal, and non–small-cell lung cancer. WellPoint intends to pay oncologists a set fee for enrolling patients in one of the approved subset of treatments in its program. The company notes that it used external oncology experts in developing the program.

Each oncologist will need to consider his or her own perspective on the program; however, some concerns related to new reimbursement models such as the above include the following:

Lack of local collaboration with physicians. Numerous collaborative programs and pilots are in development across the nation among physician groups, state oncology associations, and employers and health plans that fund the complex oncology care patients need, including laboratory work; pharmacy; imaging; and inpatient, outpatient, and emergency services at hospitals. A hallmark of these programs must continue to be an interactive discussion and analysis of results and care patterns between physicians and the purchasers.

Limited scope and focus: oncology management affects a myriad of services and resources. Effective management of oncology treatment and disease involves far more than the choice of the drugs used to treat the disease. The patient and his or her disease will react in different ways to the treatments, and each will experience symptoms and side effects that require active medical management and monitoring. This management will incur costs of imaging, diagnostics, sometimes screening and marker testing, and probably urgent care issues that may incur emergency department visits or hospitalizations. These should be taken into consideration in payment models.

A narrow definition of cost. Many programs developed external to the oncology medical community and marketed to purchasers such as health plans and employers focus on narrowing treatment choices to reduce overall cost. Cost for these programs, however, is usually defined as total dollars expended for pharmaceuticals. Programs that offer an approved list of regimens are not designed to address the total cost of care or to engage local physicians in seeking more comprehensive oncology management of total costs of care.

Lack of clinical trial presence. In medical communities, clinical guidelines and pathways all include recognition of the value of participation in clinical trials as a viable treatment option. Clinical trial participation should be considered as part of any reimbursement model.

Transparency of evidence and decision process for approved regimens. The medical community utilizes well-established clinical guidelines and pathways. These involve both rigorous academic discussion and hundreds of practicing community oncologists, academic oncologists, and other board-certified physicians in the review process. Reimbursement models should involve a transparent review process with an appropriate level of breadth, depth, and physician input.

Description as a pathway program. Oncology physicians exercise rigorous medical decision-making in matching appropriate treatments to individual patients and their specific disease. Many oncology electronic medical records are now tracking the decision process and providing information and alternatives depending upon the state of the patient and his or her disease. Electronic pathway programs exist and are being used across the country as part of the treatment decision process. A true pathway for clinical treatment involves those numerous branches of decision-making, with clinically relevant choices at each decision point.

With national concern being expressed by so many actively treating physicians and state associations regarding changes to oncology reimbursement models, and so many more advanced alternatives that do actively engage and collaborate with the treating physician community, oncology reimbursement models should continue to be reviewed and revisited. If you are in a state where a program is being unveiled, you may wish to talk with colleagues and consider what alternatives exist or what medical concerns are present.

Ultimately, participation is a practitioner’s choice. Discussion of quality and value options, and asking for transparency and accountability in revealing choices and narrowing of treatment options, are universal and appropriate discussion points for the physicians who, at the end of the day, are responsible to the patients who trust them.