Dr.McCrone, Dr.Klein, Dr.Wong.
Philadelphia, PA—Implementing path - ways to sustain community oncology and offering additional nursing and care management models are recent strategies being adopted by various practices and payers to reduce the medical and pharmacy costs in cancer management and improve the quality of care. Care Management Model “We want to create a sustainable model where community oncology can be ‘buy and bill,’” said Daniel McCrone, MD, Chief Medical Officer, New Century Health in California. “The way that we support the physician is a 4-step approach.” As can be seen in Figure 1, the 4-step model combines “fee schedule normalization, which leads to consistent payments; prior authorization, which leads to evidence-based treatment; quality improvement programs, which lead to aligned physician interests; and a high-performance provider network, which leads to quality care at optimal cost,” added Dr McCrone.
“We believe this 4-step process is exactly the way to manage the escalating pharmacy trends,” he said. “Of the 20% we could reduce a payer’s expense by, 5% to 25% of that 20% is in fee normalization, and prior authorization brings it up to about 55%. When we include the pathways, the savings is up to 75%, and consolidating the network would save 75% and more.” Care management is about improving quality of care, and the focus, said Dr McCrone, should be on reducing hospital admissions and emergency department visits. A care management program requires the following:
“Our idea was that this additional nursing would more than pay for itself by less utilization of hospital and emergency room visits,” Dr McCrone said. The duration of the active care management model is about 5 months per patient; 2500 patients enrolled in the program in its first year. Emergency department visits decreased by 10%, regardless of the treatment plan. For stable regimens for the management of breast, prostate, lung, and bladder cancers, hospital admissions decreased by 9%. But for rapidly evolving regimens, such as those for head/neck, colon, and brain cancers, there was a 10% increase in hospitalizations during the first year of the program. “In addition, because of our nurse program, 70% of patients who expired were in hospice or home hospice,” Dr McCrone added. Care Integration Networks According to Craig Deligdish, MD, Chief Medical Officer, Florida Com - pre hensive Care Network (FCCN), although much of the effort to manage cancer costs revolve around drug costs, other contributing cost factors are molecular diagnostics, advanced imaging, radiation therapy, supportive care, maintenance therapy, and endof-life care. The FCCN is based on a partnership of physicians through this clinically integrated network. This network works with technology solutions, advanced care, palliative care programs, and oncology benefit management programs, working with payers who also face challenges from their self-insured clients to try to reduce the cost of cancer treatment. FCCN “provides physicians and health plans with the tools to manage pathway and guideline adherence, creates physician guidelines, and realigns incentives around buy and bill,” Dr Deligdish said. The goals of the network include sustaining community oncology, providing technology for consistent delivery of quality care that allows both practices and health plans to measure outcomes and monitor adherence to pathways, and decreasing the administrative burden by simplifying and obviating the prior authorization process and using technology. “We focus to a large degree as a clinically integrated network,” Dr Deligdish added. “Clinical integration is an active and ongoing program to evaluate and modify practice patterns by the network’s physician participants to create a high degree of interdependence and cooperation to control costs and ensure quality.” Dr Deligdish suggested that ad - vanced care and palliative care programs need to feature an integrated care plan, focused education and patient intervention, and 24-hour access. The benefits of these programs include improved patient/physician satisfaction, decreased hospitalizations, and increased hospice enrollment. Payer–Physician Collaboration The community tries to pit managed care organizations (MCOs) against providers, saying they are 2 pieces of sandpaper coming together, said Winston Wong, PharmD, Associate Vice President, Pharmacy Manage - ment, CareFirst Blue Cross Blue Shield. In reality, MCOs and providers challenges, and goals. “We are all looking at the perfect storm coming together,” Dr Wong said. “The basis of the storm right now is the biological pipeline, which is rich in expensive oncologic agents. We also have the threat of an increase in the uninsured population becoming covered through government programs.” He said that “we’re looking at an increase in utilization overall in oncology care, which means an increase in cost. But the real issue is variability of cost because of variability of care.” What do MCOs do when faced with an increase in cost? The typical kneejerk reaction is to tighten the fee schedule. To change this, payers and physicians need a new paradigm. “We’ve taken a different approach at CareFirst, and we’re actually trying to collaborate with our physicians. We’re using a paradigm, and we’re pulling together representatives out of our oncology network and creating an oversight committee to take a look at oncology care,” Dr Wong said. His company is partnering with P4 Healthcare, which helps facilitate pathway development with physician groups, as well as monitoring data and educating physicians. This paradigm promotes individualized medicine and physicians’ discretion and provides incentives for compliance, creating a win-win-win scenario for patients, physicians, and the health plan. Dr Wong began this pathway program in 2008. “It’s a true pay-for-quality program, in that physicians who elect not to participate in our program are reimbursed at our standard fee schedule,” he said. “However, physicians who comply with our pathway standards are reimbursed at our standard fee schedule plus a differential. Hence, we are not hurting any practices who are not participating; we’re simply giving the incentive to work with us on the program.” At the end of the 2-year period, pathways for breast, lung, and colon cancers resulted in savings of approximately $17 million, the net of the incentive that was provided to physicians (Figure 2).
“We were able to show that the use of a pathway program, where you have physicians working with us, can actually function pretty well,” he said. The reason behind the program is to try to maintain the viability of the community practice, he added. Ira Klein, MD, Senior Medical Director, Aetna Oncology Strategy, agrees that to improve quality management, payers and providers need to work together. Based on results of a collaborative study between Aetna and US Oncology (Neubauer MA, et al. J Oncol Pract. 2010;6:12-18), the use of pathways did not alter the overall morbidity or mortality in patients with non– small-cell lung cancer (NSCLC) treated in the outpatient community setting. However, it did reduce the cost of drugs for patients with NSCLC. The study demonstrated a cost-savings of 35% over 12 months. “But that’s really the beginning,” Dr Klein said. “Pathway-based care should represent an evidence-based and holistic patient-centric approach. To do this with providers, we need new contractual relationships that drive quality improvements and changes, and these are about aligning incentives while keeping the focus on the cancer patient.”
