Cancer Care and Reimbursement Models: Changes Continue

Arlington, VA—Cancer care and reimbursement are changing, according to the keynote address, “Ensuring Quality Care for Each Patient: How Legislative and Regulatory Changes May Impact Community Oncology,” at the 2014 Association of Community Cancer Centers’ 40th annual meeting.

Highlighting issues pertinent to oncology care, the presentation focused on the Patient Protection and Affordable Care Act (ACA), sustainable growth rate (SGR), congressional stalemates, costs and quality of cancer care, as well as alternative payment models and value-based care.

“I did not know what shared savings was, I would never have been able to tell you what a risk adjustment case management fee was,” said Kavita K. Patel, MD, MS, Primary Care Physician, Fellow and Managing Director in the Engelberg Center for Health Care Reform of the Brookings Institution, and former advisor to President Barack Obama and the late Senator Edward Kennedy. “These are terms when I went to medical school I never learned. You should take it as a signal that cancer care and reimbursement are 100% changing. You’ve already seen it with the sequester and with references in legislation to alternative payment models and value-based purchasing.”

Trends in Healthcare
Dr Patel shared a graph demonstrating Democratic and Republican ideologies, evidencing a lessening overlap in common goals that has evolved in the last 30 years; this was the backdrop against which the ACA was passed and another SGR patch enacted. She addressed the importance of the ACA as well as Medicaid expansion in relation to cancer care; at the time of her presentation, open enrollment into exchanges offered through the healthcare marketplace had just come to a close.

“It’s worth pointing out that we have had a number of milestones that happened this year,” she said. “It’s also important to look at how much of the Medicaid expansion combined with the enrollment in the exchanges is already helping those of us on the clinical side to not be in an uncomfortable position when we meet people who can’t afford their care because they didn’t have access to care.”

Quality, costs, and access to care were also addressed. Dr Patel cited a 1999 report from the Institute of Medicine that details a fragmented, uncoordinated cancer care system that impacted patients’ ability to access care. Fifteen years later similar concerns remain, Dr Patel stated. Patients and caregivers still face poor access to information, and the gap that existed in the 1990s still exists today for those seeking information about their cancer and related issues.

“If I could have taken away that date and put in 2014 I don’t think any of you would be that shocked,” Dr Patel stated. “So it begs the question, ‘How much progress have we made in the last 15 years?’ I do believe that we’ve made progress. However, we’re still coming up against more gaps in care, variations in care, even at our best.”

Costs are on the rise, Dr Patel added, citing information from the Chronic Conditions Data Warehouse. Fifteen percent of Medicare beneficiaries who file a cancer claim represent 23% of all spending, according to their data. Furthermore, Dr Patel emphasized not just the need for chemotherapy, but also supportive services and testing that contribute to the increased cost of care.

Exploring Clinical Pathways
Turning to solutions for issues related to quality and value of cancer care, Dr Patel discussed the use of pathways and their role in improving patient outcomes. She recalled coming together with community health plan managers, large payer organizations, and the Centers for Medicare & Medicaid Services as they worked toward changing reimbursement concepts from volume to value. Many believed that pathways are necessary, but not sufficient.

“Put yourself in the seat of a policymaker, and if you’re thinking of an alternative payment model, something you would want to propose in the medical oncology setting, would you pick pathways?” Dr Patel asked. “Everybody unanimously said, ‘You start with pathways, and you need to build to something more.’”
In addition, she also addressed the move toward oncology patient–centered medical homes. The goals for this care model are straightforward: improving quality, care, and coordination, and reducing costs. Elements of the medical home in a clinical practice include adherence to clinical pathways, enhanced hours, and augmented access to clinicians/telephone triage, patient engagement and empowerment, the use of patient navigators/care coordinators, and the assumption of primary responsibility for coordination of a patient’s cancer care services.

Dr Patel discussed the advantages of the medical home, including patient-centered care, use of pathways, care-based payments, and payment tied to quality and performance. The disadvantages, she noted, include higher implementation costs, potential administrative burden, and moderate structural changes needed.
Whether the discussion or questions are related to payment models, care models, or methods of reimbursement, Dr Patel notes that the solutions often rest within the provider community. She urged participants to develop tangible solutions to help transform their practices.

“When we look for Congress or policymakers to have answers, oftentimes they turn that mirror back around and they say ‘you tell me what the solutions are,’” Dr Patel said. “They want you to show them viable solutions…they are going to say, ‘Tell us….what you want to do and propose how you will change your practice.’”

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