Payer Challenges in Oncology: Establishing Standards and Access to Quality Care

Wayne Kuznar

September 2014, Vol 5, No 7 - AVBCC 2014 4th Annual Conference


Los Angeles, CA—Payers are scrambling to devise effective strategies to cope with rapidly changing access to quality cancer care as a result of escalating costs. At the Fourth Annual Conference of the Association for Value-Based Cancer Care, John Fox, MD, MHA, Associate Vice President of Medical Affairs at Priority Health, Grand Rapids, MI, tackled changing access and payer challenges in oncology.

“For oncologists, access to healthcare is not the same as access to high-quality oncology care,” said Dr Fox. He emphasized that access to oncology care is changing, and where that care is being provided is changing as well.

Between 2006 and 2012, 469 oncology practices in the United States entered into contractual relationships with hospitals for services or were acquired by hospitals, reported Dr Fox. In addition, 288 oncology clinics closed, 407 practices were struggling financially, 131 practices either merged with or were acquired by a corporate entity, and 43 practices were sending patients elsewhere for treatment.

Payer–Provider Collaboration
Dr Fox believes that collaborating with providers is the key to controlling costs while improving quality in oncology. The collaboration between Priority Health and providers in Michigan led to the development of the oncology medical home (OMH) initiative in Michigan. The plan included payment reform, payment enhancements, and patient care reform (Table 1).

Priority Health Oncology Medical Home

The agreement between the plan and the providers was intended to last 6 months, but is now in its third year, and all participating practices have agreed to continue. This initiative was successful, because it was consistent with the way that healthcare providers want to practice medicine, Dr Fox asserted.

The downside, he said, is that Priority Health is regional and is not the predominant payer in all areas of Michigan, including Detroit. “It’s exceptionally difficult for practices to conform to, comply with, or participate in multiple payer strategies,” Dr Fox acknowledged.

In 2012, an all-payer meeting was held in Michigan to try to reach an agreement on a single set of quality metrics, quality access, and cost metrics so that oncologists would know how they would be measured. Support from the Michigan Society of Hematology and Oncology and other professional groups was high, but they were unable to convince the providers to agree. Nevertheless, “there’s a lot of enthusiasm among the providers for being able to articulate what access to high-quality oncology care means,” Dr Fox claimed.

He talked about a recent collaborative effort by the Commission on Cancer (CoC), the Community Oncology Alliance (COA), the American Society of Clinical Oncology, and the Community Oncology Medical Home project to develop national accreditation standards that would determine an OMH and could be adopted by anyone.

When practices apply for inclusion in this OMH initiative, they must agree to comply with the eligibility criteria and the care standards (Table 2), Dr Fox said.

The OMH accreditation eligibility criteria for practices include the (1) use of a certified electronic medical record, (2) leadership support for the medical home concept and accreditation, (3) staff orientation on the importance and significance of OMH, (4) willingness to share practice and aggregate patient data, and (5) administration of the COA patient satisfaction survey every 6 months.

Standards of Oncology Medical Home
The CoC and COA have developed standards for OMH consisting of 5 domains of patient care, assessments, infrastructure, and process standards. But most important, according to Dr Fox, are the methods to objectively validate care. The ability to verify care is of primary importance to payers. Accreditation standards for OMHs consist of the 5 domains developed by the CoC and COA (Table 2).

Oncology Medical Home Accreditation Standards, Draft Subject To Change

“We are evaluating this today in Michigan to decide if we can get all payers to agree that this would be the standard by which we would assess oncology practices, whether they be community-based practices or employee practices, to provide comparable information not only for payers, but also for patients,” said Dr Fox.

He questioned whether these are the standards that payers in collaboration with providers will agree to use to assess the quality of cancer care and provide incentives for access to high-quality care practices in the state of Michigan.

“For me, the key question is whether or not we can coalesce around these standards and begin to talk more about access not to oncology care but access to high-quality oncology care,” Dr Fox concluded.