Houston, TX—In Michigan, 7 oncology practices are now participating in Priority Health’s oncology medical home. At the Association for Value-Based Cancer Care second annual conference, John Fox, MD, MHA, Associate Vice President for Medical Affairs, Priority Health, Grand Rapids, MI, described the key components and goals of this model.
The oncology medical home is an innovative care model that integrates services and streamlines care as a way to achieve better outcomes. Among its collaborators are Cancer and Hematology Centers of Western Michigan, the largest private oncology/hematology practice in the state, and Physician Resource Management, which provides customized business solutions and services to oncology practices in Michigan.
“As a health plan, our focus is to create provider partnerships around the ‘triple aim,’ which seeks to balance the individual patient experience, population health outcomes, and per-capita cost,” Dr Fox said.
The oncology medical home offers many benefits to providers, payers, patients, and even manufacturers (Figure), according to Dr Fox. He said that the development of this concept relied on “full transparency and development of a lot of trust between payers and providers.”
A key goal of the oncology home model is to preserve access to oncology care in the community. “If oncology care migrates toward hospital ownership or an employee situation, society, the plan, employees, and even patients incur additional cost, without improved outcomes or improved patient experience,” he said.
“We wanted to build upon what’s been done by others, and thinking of our triple aim, we challenged the focus on drugs and pathways. We asked, ‘What about the patient?’ and that is how we developed our concept,” Dr Fox said. “We tried to design something that is a win-win for all parties.”
Most oncology payment reform models share savings when pathways reduce drug costs, but Priority Health considered whether there might be other models. The key components of their model include payment reform, enhanced payment, and care reform (Table).
Under payment reform, payers and providers agreed “that each party will get what they need out of this,” Dr Fox said. The plan pays the acquisition cost of the drugs, then takes the margin that oncologists traditionally make on drugs and turns that into a monthly case management fee for all eligible patients. Oncologists receive a standard fee, regardless of whether using an intravenous or an oral therapy, and regardless of the tumor type.
Patients who are active members of Priority Health who are receiving infused and/or oral chemotherapy, independent of when the treatment was started, or who are receiving palliative care services, are eligible to participate in this model, regardless of whether the treatment is according to pathways. Patients are not eligible if they receive selected drugs for maintenance chemotherapy; receive chemotherapy in the inpatient or outpatient hospital setting; no chemotherapy, or radiation only, during a calendar month; or if they are enrolled in a hospice.
“Physicians have said for a number of years that one of the reasons they need margins on drugs is to provide high-quality cancer care, and we created the case management fee concept to cover services they have not been compensated for in the past,” Dr Fox explained. “It’s simple to do. The oncologist doesn’t bill. We pay them automatically every month.” These high-quality cancer care services include:
Separately payable fees include board-certified genetic counseling, advanced care planning, and psychological counseling. Reimbursement remains unchanged for evaluation and management codes, infusion fees, and laboratory and imaging.
The model also pays an “infrastructure development fee,” which is intended to help defray the cost of care management changes. Care management reforms under the plan include:
“We recognize the physicians for their efforts to reduce avoidable care, such as emergency room visits and hospitalizations,” Dr Fox noted. “If successful, they will share in the savings. We believe that oncologists will find that this enhances their reimbursement in the long-run.”
Physicians are asked to measure their performance against what they believe is the optimal pathway, and to perform well on a number of utilization and quality performance metrics. Key domains are end-of-life care, office triage for case management, and chemotherapy compliance.
