Lofty Goals Being Set For Reimbursement Reform

Those seeking to reform oncology reimbursement for physicians have set lofty goals: create an equitable method for reimbursing oncologists for the entire continuum of care of these complex patients, and provide better care for patients— reducing adverse events, emergency department (ED) visits and hospitalizations, while lowering the overall cost of cancer treatment in America.

It is hard to argue in favor of the status quo of fee-for-service and average sales price (ASP)-based reimbursement; critics charge that the current payment model incentivizes the use of expensive treatments over other treatments that are just as effective and less expensive, which increases the costs of care and can lead to more toxicities. Cancer care certainly is expensive: Direct medical spending on cancer treatment in the United States was $124.6 billion in 2010, according to the National Cancer Institute, which projects that cancer care will cost upward of $207 billion by 2020.

Barbara L. McAneny, MD, CEO of the New Mexico Cancer Center, in Gallup, set up an oncology patient-centered medical home (OPCMH), which uses a team approach to care for the patient, a growing trend to reduce the fragmented delivery of primary health care. Dr. McAneny received a CMS Innovation grant in early 2012 to duplicate her ideas in six other community oncology practices.

Another goal of the OPCMH is to provide a framework for better-coordinated, evidence-based care. Under such a framework, “the oncologist and everyone else on the team can work to the top of their license,” Dr. McAneny explained. “Oncologists can focus on what we do, which is discussing treatment options with patients, setting up treatment plans, overseeing patient care, making sure that treatment happens properly, and, if there are any side effects or complications, [making sure] they are taken care of, and then watching for any recurrence or new problem.”

Triaging cancer patients is an important part of Dr. McAneny’s services. Anyone who calls the cancer center with a variation of “I’m sick” is sent to the triage nurse, who uses the electronic triage pathways to direct that patient’s care. For instance, if a woman with breast cancer calls because she is having pain in her chest, the nurse will help her decide whether that pain is due to her cancer or she is having a heart attack. If she is having a heart attack, she will be directed to call 911 and go to the ED. “On the other hand, if she is having chest pains because she is a 40-year-old woman with breast cancer that has spread to her ribs, and her ribs hurt, I don’t want her going to the ED as a heart attack and having a bunch of cardiac testing done to her. I want her to come to the office,” Dr. McAneny said.

Dr. McAneny’s cancer center sees about 3,000 new cancer patients a year and, although she and the other community cancer centers covered by the grant still are collecting outcomes data, she estimated that hospitalizations have dropped by between 30% to 50%, ED use has decreased and patient satisfaction is routinely in the 90th percentile. “And we are saving money,” she said, “about $4,000 per patient.”