Is it a simple matter of pay for volume vs. pay for value, or is the situation far more complicated?
CareFirst, the Maryland–Washington Blue Cross Blue Shield plan, has transformed its first-generation oncology pathway program into a second-generation program that incorporates medical home principles. The change reflects CareFirst’s continuing effort to encourage oncologists to improve care on a broader scale than chemotherapy regimens.
“The most important part of this whole program is engaging oncologists to think differently,” says Daniel Winn, MD, VP, and senior medical director at CareFirst. “It’s a unique specialty because of the difficulties physicians face every day. Complex treatment decisions are coupled with a constant focus on the cost of care driven by high-cost medications. If we can mitigate the cost and economic issues, then physicians can focus on providing high-quality care.”
“The oncology medical home is an effort to engage physicians in new ways,” says Daniel Winn, MD, medical director at CareFirst.
CareFirst’s oncology medical home has two major components. The first is a physician payment model that provides incentives to focus on cognitive services and patient management (evaluation and management services) rather than the margin from drugs that underlies “buy and bill,” the common payment arrangement in oncology.
CareFirst sought to maintain adequate levels of practice revenue by increasing payment for cognitive services by 300%. The second element is expanding the care model to move beyond medication therapy and focus on the continuum of care.
A recent study of the effect of the new physician payment model showed that it did not substantially alter physician behavior in comparison to the buy-and-bill model. In turn, that has raised questions about whether physician payment arrangements receive too much attention as a determinant of physician behavior and the high cost of cancer care. The study compared performance in eight medical home practices to a matched set of seven practices continuing under the first-generation buy-and-bill payment model.
One year after conversion to the new model, the average number of established office visits per patient remained stable in oncology medical home practices – 3.7 visits before conversion vs. 3.8 afterward. The percentage of chemotherapy administrations per patient remained steady in both groups, with approximately eight administrations per patient in each group for the pre- and post years. Likewise, the percentage of patients who received chemotherapy remained stable in the pre- and post years for both the medical home group and first-generation practices, at approximately 15%.
The percentage of patients who received all-generic chemotherapy regimens was a key endpoint. There was no difference. However, use of generics increased by more than 40% for both the medical home providers and the control group. The dramatic increase was related to patent losses for gemcitabine, docetaxel, irinotecan, and oxaliplatin.
The study has many limitations. Most notably, there may be selection bias because physicians could choose whether to participate in the medical home model. Also, the behavior of the physicians may have been influenced by their previous three years of practicing under pathways.
The study also did not report on the full range of prescribing behaviors or the extent to which medical home and control group physicians adhered to pathway therapy regimens.
Despite limitations, Bruce Feinberg, DO, CMO for oncology at Cardinal Health Specialty Solutions Services and the study’s primary author, concludes, “For physicians who have been in mature pathway programs, removing all profit margins from drugs did not further alter their prescribing behavior.”
That conclusion serves as a springboard to a broader issue in cancer care. “Is resolving the pay-for-value versus the pay-for-volume debate one of the critical solutions for improving care and controlling costs, and what is the driver of the utilization of therapies? Is it reimbursement or is it more complicated?” asks Feinberg. “My concern is that the driver of the volume is more complicated than economic incentives. Our medical culture values new treatments over old, more over less, and now versus later. That philosophy characterizes patient perspectives and physician perspectives in the way we manage elevated PSA, abnormal mammograms, and cardiovascular risks.”
The drivers of volume are not solely economic incentives, says Bruce Feinberg, DO, who is the CMO for oncology at Cardinal Health Specialty Solutions Services.
He adds, “If we don’t address the cultural factors in our delivery system, then I am concerned that we may go down the wrong road for improving care because we are not addressing the drivers.”
Feinberg says that the study’s real significance is that it points out misdirected criticisms and oversimplification of the challenges in improving cancer care.
“The New York Times editorial offering a plan to fix cancer care and the Institute of Medicine report on the crisis in cancer care blame volume-based payment for high costs, but physician behavior is extremely complex. If we try to reform health care based on notions that are oversimplified, then we are going to miss opportunities for real improvements.”
Feinberg has an alternative to blaming payment models for the high cost of cancer care. “The way you modify physicians’ behavior to focus on value and quality is through active physician engagement. We need to make them aware of situations and aid them in decision support.”
He provides an example. “The National Comprehensive Cancer Network guideline for breast cancer says there is no benefit in combination therapy for the vast majority of patients with metastatic breast cancer and that sequential monotherapy is the way to go. When we looked at claims in one program, we found that in the first three lines of treatment, two thirds of patients were getting combination therapy. When this type of information is presented to doctors in a pathway program, the heightened awareness of actual performance coming from their peers is able to drive changes in behavior.”
CareFirst’s Winn says, “The oncology medical home is an effort to engage physicians in new ways on comprehensive cancer care. We’ve added chemotherapy in the last weeks of life, palliative care, and hospice as performance targets. We created a sophisticated palliative care and hospice network as a resource to physicians and we’ve built palliative care and hospice algorithms into the pathway software to make it easier for doctors to make decisions about the appropriate time for referrals.”
CareFirst is also working to connect its case managers more closely to physician practices. It also has maintained its focus on the cost of care, and now it has added total care costs to its physician scorecards.
The oncology medical home reflects a trend in cancer care for payers and oncology practices to explore new cost-control and quality-improvement models that extend beyond chemotherapy. Those models include oncology ACOs, bundled payment arrangements, and episode-of-care models.