We've seen payers and providers increasingly interested in experimenting with oncology payment models over the past few years. To assist cancer programs that are exploring alternative payments or just want to stay on top of this trend, we've provided examples and links to additional information below.
- Memorial Sloan Kettering Cancer Center (MSK) and Carrum Health teamed up to offer comprehensive cancer care bundles for a single, upfront payment from employers. The bundle packages cover up to two years of in-person treatment at MSK for eligible patients with non-metastatic breast or thyroid cancer, as well as remote diagnosis, treatment planning, and care guidance for all forms of cancer. Read more about the partnership and bundles here.
- In September 2020, CMS and Center for Medicare and Medicaid Innovation (CMMI) released the long-awaited final rule for its Radiation Oncology Model (RO Model). The aim is to test whether transitioning to prospective, episode-based, site-neutral payments will reduce Medicare spending on radiation therapy while preserving or improving care quality. Under the proposed RO Model, set to begin in January 2022, participants within randomly selected Core Based Statistical Areas will receive prospective payments for 90-day episodes of care for Medicare Part B beneficiaries with one of 16 different cancer types. To learn more about the model, read our answers to your peers’ top questions. To prepare your organization, check out if your hospital has been chosen to participate, conduct a readiness assessment, read our four-step guide, and learn how other cancer programs are preparing.
- CMMI's Oncology Care Model (OCM) is a voluntary program for physician practices that prescribe chemotherapy. 127 practices and 5 payers are currently participating in this six-year pilot in an effort to provide higher quality, more highly coordinated care. At our first Oncology Care Model panel, panelists described the top challenges of participating in the OCM and specifically mentioned data analytics to be one of their greatest concerns. Check out our OCM evaluation blog post or review these slides for the latest results on how OCM participants are performing.
- MD Anderson and UnitedHealthcare successfully launched a bundled payment program in 2015. The bundle covered the total cost of care for 88 head and neck cancer patients over the course of two years and demonstrated the first attempt to prospectively bundle multidisciplinary cancer care. Some of the challenges with this pilot included the manual work to write claims for bundled payments and addressing new therapies as they emerge on the market. While the bundle has ended, it proved a valuable learning experience for both the provider and payer, demonstrating that bundles in oncology are possible from an administrative and logistical standpoint. We provided an update on this pilot as part of our 2018 Oncology State of the Union; review the slides here.
Editor's note: Oncology Rounds is published by Advisory Board, a division of Optum, which is a wholly owned subsidiary of UnitedHealth Group. UnitedHealth Group separately owns UnitedHealthcare.
- 21st Century Oncology and Humana negotiated bundled payments for radiation therapy for 13 frequent diagnoses, including breast, lung, and prostate cancers. A study evaluating the bundle found that providers' overall use of guideline-based care was largely unchanged; however, patients with bone metastases and prostate cancer patients experienced a significant increase in the rate of guideline-based care after the introduction of case rates. In May 2017, 21st Century Oncology filed for Chapter 11 bankruptcy protection, but it is unclear whether their bundled payment program played any role in that outcome. For more information see p.15 of Innovations in Radiation Oncology.
- Regional Cancer Care Associates (RCCA) and Horizon BCBS are piloting bundled payments for breast cancer cases being treated with chemotherapy. The program is facilitated by a proprietary data platform, COTA, which assists with the development of individualized patient treatment plans and tracks patient outcomes.
- BCBS of California and Valley Radiotherapy Associates (VRA) entered an episode-of-care payment agreement for breast cancer patients who require radiation treatment. The case rate, which went into effect in May 2016 and lasted around 18 months, covered all services provided for treatment with the aim to create develop long-term price predictability. In 2018, VRA radiation oncologists joined City of Hope Medical Group.
- The first phase of UnitedHealthcare'sepisode-based payment for medical oncology ran from 2009 to 2012 and included five independent oncology practices. The initial pilot resulted in total net savings of $33,361,272, representing a 34% reduction in total costs of care. Surprisingly, spending on chemotherapy increased 179%. UnitedHealthcare is currently running its second phase, and we will share results as soon as they are available. We provided an update on this pilot as part of our 2018 Oncology State of the Union; review the slides here.
Shared savings programs and oncology ACOs
- Advanced Medical Specialties, a large regional payer, and Baptist Health South Florida developed the first oncology ACO. In its first reconciliation year the ACO achieved savings of approximately 2%. Three years after its formation, Advanced Medical Specialties and Baptist Health South Florida consolidated to form the Miami Cancer Institute, which continues to report cost savings.
- Moffitt Cancer Center and Florida Blue have also entered into an agreement for an oncology-specific ACO. Preliminary studies show a significant reduction in inpatient readmissions, improved generic drug prescribing, and increased guideline agreement. We provided an update on this pilot as part of our 2018 Oncology State of the Union; review the slides here.
- ASCO's Patient-Centered Oncology Payment (PCOP), released in 2015, encourages high-quality cancer care, while incentivizing oncologists to improve their practice. The program offers oncologists three options to transition into an alternative payment model, including basic, consolidated, and bundled payments. PCOP modeling suggests that practices that successfully implement the APM would reduce drug spending by 7% and emergency room utilization by 30%. The overall reduction of the cost of care could amount to 8.2% for an episode of chemotherapy. However, we are not aware of any practices actively involved in the PCOP program. ASCO released an updated version of the PCOP model in May 2020.
Oncology medical homes
- Consultants in Medical Oncology and Hematology: This Pennsylvania oncology practice is contracted with two regional plans and has implemented care coordination and evidence-based care measures that led to a 51% drop in ED visits, a 68% drop in inpatient admissions, and savings to payers of $1 million per physician per year.
- COME HOME: Funded by a three-year CMMI Innovation grant, this initiative is transforming seven oncology practices around the country into oncology medical homes by implementing care pathways and elements of care coordination. CMMI reports a reduction in ED visits of about 1% and a 3.5% reduction in 30-day readmissions.
- ASCO and COME HOME are now collaborating to transition community practices to value-based care models by restructuring reimbursement around the services that cancer patients need. ASCO is currently recruiting oncology practices for the program.
- Tennessee Oncology and BlueCross BlueShield (BCBS) of Tennessee announced an oncology medical home program in October 2021 that will award Tennessee Oncology providers financial incentives or penalties for care coordination and documentation. As part of the program, the organizations will use data analytics to track patients throughout their cancer care journey and ensure Tennessee Oncology providers follow best practice guidelines and provide patient-centered care.
- Priority Health's Michigan Oncology Medical Home Demonstration Project: This partnership between a regional payer and a group of oncology practices funded oncology medical home care transformation efforts with an enhanced payment model. The model replaced the drug margin with a per-member-per-month care management payment and saw first year savings of $550 per patient, along with reductions in inpatient admissions and emergency department visits.
- Moffitt Cancer Center and Aetna Oncology Medical Home Collaboration: Moffitt and Aetna's medical home initiative has been described as a key step in Moffitt's transition to value-based payment. The oncology medical home agreement emphasizes access measures, such as culturally and linguistically appropriate care, open scheduling, and expanded hours.
- Aetna and RCCA Collaborate on an Oncology Medical Home: This model became available in September 2016 to all patients who receive care at RCCA's clinics in New Jersey and Maryland. Through this model, RCCA has the responsibility to arrange appropriate care and physicians are incentivized for improved health, better costs, and a positive patient experience. And, for its part, Aetna now has 21 practices enrolled in their oncology medical home initiative.
- Horizon Healthcare Services and RCCA have created a pilot program to continue patient between chemotherapy treatments. To do so, nurse navigators will proactively address patient concerns and intervene if complications arise during the interim. The navigators will also be responsible for connecting patients with transportation options and access to other facilities across the continuum of care.
- Cigna Collaborative Care for Oncology, a model similar to an oncology medical home, is intended to improve affordability and provide cancer patients a point of care that ensures all of their needs are met. To help providers meet this goal, Cigna provides participants financial incentives, data, and operational support. In return, participating practices are required to provide patients 24-7 access, provide an RN oncology care coordinator for attributed patients, utilize a shared decision making process supported by evidence based guidelines, and report on six quality metrics including palliative care assessment and distress screening. Cigna’s program is currently being piloted at several independent oncology groups and practices throughout the U.S., including the Virginia Cancer Institute in Richmond, Va., Regional Cancer Care Associates in Hackensack, N.J., and Florida Cancer Specialists & Research Institute in Fort Myers, Fla. Because the program is new to oncology, there is little data on outcomes to be shared yet. For more information about the program and oncology medical homes more generally, review this excerpt from our 2018 Oncology State of the Union.
Payer pathway programs
- Anthem’s Cancer Care Quality Program is a value-based oncology payment model that uses pathways to encourage physician adherence to evidence-based practices and cost-effective care. Approximately two-thirds of Anthem insured patients with breast, NSCL, or colon cancer were treated on the pathway program in 2015. The Cancer Quality Program uses pathways developed by AIM Specialty Health to help physicians select interventions based on clinical effectiveness, favorable toxicity profiles, and cost to patients. Physicians can receive enhanced reimbursement if they adhere to the pathways.
- UnitedHealthcare’s Cancer Therapy Pathways Program, which began in January 2020, offers financial rewards to providers whose practices demonstrate at least 75% pathway adherence during six-month performance measurement periods.
- Blue Cross Blue Shield of North Carolina (BCBSNC) began a new Medical Oncology Program on April 1, 2017, which also reimburses physicians at a higher rate if they adhere to the AIM Cancer Treatment Pathways.