Dr Bhuvana Sagar Discusses Payment Reform in Oncology

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Bhuvana Sagar, MD, national medical executive, Cigna Health Care, offers insights on implementing payment reform models in oncology after a session at the 2020 Community Oncology Alliance Payer Exchange Summit.


Bhuvana Sagar, MD, a national medical executive with Cigna Health Care, gave her insight on successfully implementing payment reform models in oncology after participating in the session "Deep Dive: Updates From Three Ongoing Oncology Payment Reform Projects" at the 2020 Community Oncology Alliance Payer Exchange Summit.


The word “evolving” came up several times during the discussion with regard to making models work over time for oncology providers. Given Cigna’s national footprint, how do you strike the right balance between a standard you can scale and making period changes to reflect the feedback you receive?

That's a very good question. I think overall, a lot of things that apply to community oncology do not apply to hospital-based practices. As you know, the practice setting is different. The methodology is different, the way the physicians operate is different; some of these institutions are NCCN [National Comprehensive Cancer Network], or NCI [National Cancer Institute] cancer centers, [so] the way they manage care is a little bit different from the way our community oncology practices manage care. So, over the years, and initially, our initial model was [introduced in] 2015. Our model was primarily like an Oncology Medical Home. We were a little ambitious, we had a lot of risk adjustment built into the model to understand cost differences that can be accounted for by advanced stage disease or early stage disease. We've also looked into doing a total medical cost model with episodes. So we've looked at the entire gamut, we get feedback, and it is not an easy thing to do on our side. Also, we also have a lot of administrative burden as we've done and as we do try to operationalize these models. So it does take a lot of effort on our end, to get the feedback in to make the changes necessary. And then there's a lot of contracting language that goes into play and several folks that work on the model to make things happen. So I would say that it's not an easy task. But we do try to get feedback from all the providers ... how Florida practices [is] not exactly how New Jersey practices. So we did take those comments into count as we do that.

You mentioned that the feedback you get from community providers may be different from hospital/facility providers. What are some specific differences that these groups raise in implementing your model?

[At] a lot of these large institutions, they have an entire division that works on breast cancer, for example. So they have breast cancer division, the lung cancer division, and each division operates a little bit differently. And ideally, when we implement models, we like to have like a single point of contact that is available to connect with our clinical resource or non-clinical resource, so that there's that collaboration between the two of us, [the payer and] the provider as we move this forward. So, you know, we've experienced some challenges because of the way they are set up, and how their operations are set up. And so they may, they don't necessarily have one nurse, they have probably 50 different nurses that [perform] that function of navigator or coordinator, so to speak. That's just one tiny sliver of things. But I think a lot of the big hospitals, they also have a consistent pathways or consistent methodology, the way they operate, they also have greater access to clinical trials. Community oncology functions a little bit differently. [Many] times are able to provide that single point of contact. [Often] their physician leadership is very closely engaged with our teams. They also have team-based care where the teams are smaller, the scales are much larger in a hospital based system. I think that's probably like the best description I can give.

Your comment about reducing administrative burdens and limiting measures to only those that are necessary was well-received. Is there a specific method Cigna is using to identify burdensome steps/measures/processes?

So, when we started initially, we came up before OCM [Oncology Care Model] came out. And so we had reasonable measures and once OCM came out, we tried to align as much as possible with OCM to make it easier on providers. That being said, any minor change in the measure itself, measure definition, makes it a completely new measure. So OCM has a different methodology for collecting data from providers, and obviously, we as Cigna Health Care, [don't have] the resources that CMS has to be able to get that level of detail. So what we had to do was, at that point, once we made the changes, and we had to [take another look] at them, understanding the challenges providers had in submitting some of these codes, and [ask], are they suffering pain management, for example, depression screening, are they doing adequate depression screening and addressing those challenges with patients?

So, we tried to simplify at that point to say, OK, we will accept additional quality certification. We've tried to simplify as much as possible, but there's always administrative burden with any of these value-based care models we're trying to do, because you're trying to change the way we practice and we operate as a oncology ecosystem. So, I think we have made significant progress, I believe. But I think like as any change you make, like I told you is going to make a change in our model and contracting language, things like that. So, overall, we do take into account feedback. We can't always respond to every single [piece of] feedback, but we do make reasonable changes and try to simplify things because it's important for us to keep it simple and standardized because we are a national payer. We want to make sure that it's a model that we can operate and implement and do it with as little burden as possible.