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The Evolving Oncology Medical Home

March 2015, Vol 5, No 2
Dawn Holcombe, MBA, FACMPE, ACHE
President, DGH Consulting, South Windsor, CT

Directors from Aetna, Inc, gathered recently with a panel of thought leaders to explore the evolution of the oncology medical home (OMH) against the backdrop of the company’s experiences in this area. The discussion, held in November at the Cancer Center Business Summit, highlighted initiatives Aetna has undertaken and options the company has explored in recent years.

Led by Ira M. Klein, MD, MBA, FACP, National Medical Director, Clinical Thought Leadership, Office of the Chief Medical Officer, Aetna, and Michael Kolodziej, MD, National Medical Director, Oncology Solutions, Aetna, the panel also featured Maria Sipala, Director, Strategic Planning, and Amy Supraner, Strategic Planning Manager, both from National Network Contracting, Aetna. Barry Russo, MBA, CEO, The Center for Cancer and Blood Disorders, and Kathleen G. Lokay, President and CEO, Via Oncology, rounded out the panel.

Pathways are often discussed as potential solutions for oncology management, but the panelists emphasized that pathways are simply a minor tool in a larger toolkit being developed for evolving programs and payer–provider relationships. Drs Klein and Kolodziej indicated that Aetna has had success with several options that were piloted in recent years among a diverse group of practices. This may be in part, they noted, because Aetna has national reach but generally does not hold the highest share in any given market, which helps to keep the volume of patients in these pilots manageable for Aetna and participating practices.

Aetna has examined and experimented with external vendors of pathways and oncology management, but is now taking an agnostic approach to pathways, the team noted: as long as an oncology practice is satisfied with a formal, evidence-based, documentable electronic pathways program, Aetna is not going to push a vendor of its own choosing on the practice. It was noted, however, that Via Oncology currently provides a pathways solution to 10 of the 13 practices in formal quality programs with Aetna.

Consistency, accountability, responsibility, and flexibility are outputs that Aetna seeks from partnering physician groups, and it does not want to overthink practice drug choices or overmanage treatment choices, according to Drs Klein and Kolodziej. However, practices will be penalized in the near future if those choices do not prove to be responsible. The practices currently working with Aetna have changed their culture and practice perspectives to be substantially more patient-focused, which may also change what practices come to expect from the products they use and what they look for from the pharmaceutical industry.

The company continues to work on a general OMH-type model that relies on formal evidence-based decision-making documentation and reporting capabilities. It also entails a commitment by participating practices to patient-focused initiatives, including management of hospitalizations and emergency department visits through attentive triage and patient management, pain management, formal care plans and advance care planning, and a commitment between practices and Aetna to collaboratively review the scope and costs of care.

In addition to discussing OMH-based initiatives, panelists also participated in an active question-­and-answer session. One audience member questioned whether Aetna has had to contend with simultaneous OMH and accountable care organization (ACO) models within the same practice. The Aetna team responded that yes, this has occurred, and it is challenging.

The ACO model is more focused on primary care and has a high-volume, low-cost attribution, whereas the OMH model is the opposite: low volume, but high cost. ACOs in the future will likely benefit from partnering with subspecialists who can manage these sickest patients most effectively, the Aetna team indicated; however, the issue of how to involve specialists or how best to allocate or share funds has not yet been addressed.

Another question addressed whether Aetna’s emerging OMH model was also being applied in the hospital setting, particularly since the majority of care in many states is now hospital-based. Aetna has seen some interest in its current model, the team noted, but also a lack of interest from hospital systems that are doing well under the systems they have in place. This often leads to arrangements with innovation and flexibility within community practices, which is good for patients and the community.

The Aetna team suggested that there is generally a baseline patient volume to make pilot programs work: approximately 75,000 to 100,000 covered lives in a market might make sense. The number of patients with breast, lung, and colon cancer seems to normalize and make sense when practices see more than 50 patients, and 100 patients covered through Aetna becomes a substantial enough volume to start looking at partnerships; this number might be fewer in the Medicare population.

The OMH model being used by Aetna and its participating practices is still a transitional model, and the concept of shared savings has its own unique issues, the Aetna team noted. Exploration of shared savings potential allows payers to benchmark the size of an opportunity and perhaps the size of an eventual management payment. Current programs and pilots allow both Aetna and participating practices to better understand the cost structure of oncology treatment and care. They are also now looking at cost variation by common disease, biological determinants, and other variables.

Mr Russo and the Aetna team stressed the value of their relationship is not limited to the financial elements of shared savings and management; rather, they are both developing an understanding of how to implement pilots at safe, reasonable volume levels. Aetna encourages its partner practices to explore similar programs, even based upon the Aetna model, with other payers, in the hopes of shortening the learning curve and simultaneously raising the bar for oncology management consistently across a given market.

At the conclusion of the session, the Aetna team presented its view of the future of oncology management: pathways have a role for compliance and adherence, and practices that do not use a formal, electronic pathway program often believe they are treating on pathway, but they usually are not. With a clinical decision support tool that the practices choose and trust, compliance rises, which facilitates the development of a solid process and, from that, a reasonable management fee.

A reasonable management fee may in the future lead to reduced reliance on pathway performance and compliance reporting; however, there will be winners and losers. Some practices will rise to the challenge and manage care in a manner that meets the needs of the patient, the payer, and the practice, and others may struggle, and then struggle further if they cannot perform at a level to justify a higher management fee. The first step is with pathways and the general concept of an OMH.

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