Evolution and collaboration are the fundamentals of bringing oncology payment reform plans to fruition, say 3 professionals on the front lines.
One began as a conversation “over a cup of coffee” on how local employers could save money and retain talent. A second is a collaboration among oncologists and their state’s largest payer that grew out of an intervention in cardiology. And the third is a nationwide model that takes feedback from many types of practices, markets, and hospitals, and adapts a model over time to serve them all.
The word “evolution” came up repeatedly during the session, “Deep Dive: Updates From Three Ongoing Oncology Payment Reform Projects,” during Tuesday’s opening day of the Community Oncology Alliance Payer Exchange Summit, as COA’s Bo Gamble, director of Strategic Practice Initiatives, guided a discussion of how payment reform works in trenches. Joining him were:
Gamble asked each presenter to describe their group’s model, and then he asked: what makes it unique? Woofter described a model “that started out of necessity,” because an employer came to the oncologists in search of ways to reduce costs. From there, a direct employer contracting relationship emerged, with quality programs and incentive payments for physicians to reduce costs. The resulting arrangements led to the creation of Integrative Care Partners (ICP), centered in South Bend, Indiana, which works across 200 physicians in oncology and beyond, doing everything from sharing data to getting patients pricing on magnetic resonance imaging (MRIs).
While a third-party administrator is involved, Woofter described a relationship where the real accountability is to the people paying the bills: “My belief is the ultimate payer is the patient and the employer,” she said.
Cohen said BCBS of Michigan started with alternative payment models (APMs) 22 years ago with an interventional cardiology program, with goals of reducing variation in care and improving quality by having physicians look at their own data and then work with experts to find ways to improve. From there, the model has moved in 17 other conditions, including various areas of oncology—including gynecological oncology, radiation oncology, prostate care, and kidney masses. Medical data is extracted into clinical registries, and BCBS also works with a pharmacist to advise on ways to improve.
What makes the Michigan program unique? “Our model is an engagement of providers,” Cohen said. Through Collaborative Quality Initiatives, BCBS of Michigan works with experts to promote regional meetings for physicians in each specialty to share data and best practices; nearly all the state’s oncologists participate. Quality improvement cannot be something that is done once every 3 months; it must be ongoing, he said. “The model we've used is really to empower the physicians to self-optimize their care, utilizing clinical data that they have, to learn and share best practices.”
For Cigna, Sagar said, quality improvement work started in primary care and grew into the Specialty Care Collaborative; work with oncologists began in 2015, before the Oncology Care Model took effect.
Just sharing information was an important first step, she said.
“There's a lot of information that the providers are not aware of, that we have access to, and then there's information that we don't have access to, that they have access to,” Sagar said. “We've gone through several iterations of the model because as you start working in the space, you recognize a lot of the challenges and you understand that you have to keep making progress.”
Cigna’s model also seeks to work closely with physicians, she said, explaining later in an interview that when working with community oncology practices, it can be easier to engage directly with physicians, whereas with major academic institutions, there may be a different nurse coordinator for each division.
Gamble asked about the BCBS of Michigan pharmacy services pilot program, which Cohen said has been well-received and may reach 4 sites soon. It’s designed for managing higher-risk patients, who have more complex therapeutic regimens. The program, Cohen said, will help oncologists improve patient outcomes by increasing collaboration to manage symptoms and toxicities. “This is not the idea of a heavy-handed health plan, pushing something down on you,” he said. “It just increases the ability to have more collaboration among the oncologists.”
Gamble asked about engaging employers in payment reform models, and Woofter said when she started working with them, she assumed they knew more about the health care system than they did. Just the process of collaborating has helped them gain knowledge. “When you went in with a non-judgmental approach and opened up that transparent dialogue, you've educated them along the way, help them to be better consumers."
And it’s not just the employers who benefit. “I'm very proud of most of our employers—not all, but most—have passed savings along to their employees. And they've helped employees to understand and there were incentives there,” Woofter said.
All 3 panelists spoke of the importance of continuing to gather feedback and update models; Sagar highlighted the need to not add to the workflow, and Cohen noted that physicians don’t want to have to follow multiple different programs for each payer. Gamble raised the issue of standardization: is this where things are headed?
Sagar said some things should be standardized, but some cannot. “Oncology is much more complex,” given the different stages and types of cancer. “There’s obviously the risk adjustment component of it. If you’re thinking about a fundamental medical home model, I think some of those measures could definitely be standardized and need to be standardized.”
But she also pointed up a point Cohen had raised, that each practice is unique, and that must be acknowledged, too. “We don't want them to change everything they're doing,” she said, but practices should meet a “basic quality threshold, and make it easy for us payers and employers to be able to get that information and data.”
“I like that answer,” Gamble said. “Maybe we'll just say, here's the path. Let's all go down the same path. And let's see what great things happen.”