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Learnings From Priority Health's Oncology Payment Reform Model


To speak about the success and continued development of Priority Health's payment reform model in cancer care, John Fox, MD, medical director at Priority Health, joined Dennis Zoet, chief business development officer at Cancer and Hematology Centers of Western Michigan, on a panel at the Community Oncology Alliance Payer Exchange Summit.

A collaboration between a regional commercial payer in Michigan and community-based practices, which piloted in 2011, was developed with the sole objective of improving care delivery in the oncology space and moving away from the fee-for-service model.

The model was extremely successful, and to speak about its success and continued development after 6 years, John Fox, MD, medical director at Priority Health, joined Dennis Zoet, chief business development officer at Cancer and Hematology Centers of Western Michigan, during the Community Oncology Alliance (COA) Payer Exchange Summit, October 29-30, in Tysons Corner, Virginia.

Fox told the audience that the model was a version of an oncology medical home model, that does away with episodic care. The 3-pronged focus included:

  • Payment reform: The transition to a performance-based care delivery system included changes within drug reimbursement, addition of a care management fee, shared savings, infrastructure development, and enhanced services.
  • Care redesign: This included agreement on preferred regimens, care management, advance care planning (ACP), and survivorship
  • Performance measurement

“We realized that change is hard; it takes time, experience and commitment; and it takes money,” Fox said. Zoet’s practice has successfully adopted these change for 6 years.

While implementing changes to adopt the pilot was easy, using that as a stepping stone to participate in the Oncology Care Model (OCM) was much harder, Zoet said. “Our staff thought [the Priority Health pilot] was a one-off, so they bought in to some extent. What changed the deal was OCM participation. That was a big change as it looped in 60% of our patients,” he said.

Zoet explained that internal champions for these programs played an important role. “We had both physician and administrative champions,” he said. The practice saw staff that didn’t buy-in to these changes leave the practice, “but those who were sold stayed on and moved forward with us.”

The practice had to add staff to their payroll to implement some of the required changes, including a same-day care clinic and moving over to OncoEMR, the platform from Flatiron Health..

The conversation then shifted to the important role of data in practice transformation. Zoet explained that his practice extracted data through 2 different vendors in addition to the claims data that CMS provides, “because they all look at the same data differently.” He emphasized that data transparency was key. Physicians reviewed the data as a group as well as individually. Additionally, the data were sorted based on each specialty, which is key in oncology.

Zoet then provided a case study of how data analysis helped them realize that the hospital that was conveniently located across the street from their practice had a 65% admission rate among the practices patients who visited the hospital’s emergency department (ED), about 40% higher than another hospital that was a little farther away.

The practice also hired social workers and encouraged ACP discussions, which he said have evolved into care coordination programs.

“We have started having frequent conversations with our physicians on the cost of drugs,” Zoet said, because physicians have, traditionally, not been aware of drug prices.

“Now that they have to pay for it, they are,” Fox said.

It’s not a win-win situation, however, and the practice continues to face challenges with the model and continues to evolve as well. Zoet indicated care coordination, ED inpatient visits, and data exchange as their top challenges.

But he is also hopeful that changes such as exploring artificial intelligence and hiring an internist, which the practice is planning to adopt, will make a difference.

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