In an interview with the Association for Value-Based Cancer Care (AVBCC), Jennifer Malin, MD, PhD, Medical Director of Oncology at WellPoint, emphasized that patients should remain the central focus in novel or innovative reimbursement models.
AVBCC: Dr Malin, you have talked about the importance of keeping patient-centered care the focus of reimbursement strategies. How can this be done while still controlling cost?
Dr Malin: There is so much talk about creating value, but achieving that goal in oncology care is complex. Oncology is a complicated field to address, because the stakes are so high. What payment models need to consider are the best ways to combine cost control with patient-centered medical care. Some standard payment models—the so-called “capitation episode-based payment model” for example—give physicians a lump sum to provide care for a population or for 1 patient throughout the course of care. Other models focus on episode-based payment.
AVBCC: What is being done at WellPoint that you consider patient-centered?
Dr Malin: For our oncology medical home, for which we have an ongoing pilot, we pay oncologists a disease management fee. We still pay for the drugs and the office visits, but we also give providers a fee for caring for the patient, for selecting the most appropriate evidence-based and guideline-based care, for being value conscious, and for making sure patient care is well coordinated and that their symptoms are effectively managed so they do not have to turn to the emergency department unnecessarily.
AVBCC: How do you verify that physicians are using the disease management fee appropriately?
Dr Malin: We only have the oncology medical home pilot in 1 practice at the moment, but we hope it will be scalable. For this initial program, we are collaborating with the Wilshire Oncology group in Los Angeles, CA. The group has instituted a proactive program to reach out to patients who are receiving treatment and confirm that their symptoms are being addressed. We meet with the physicians and staff regularly, and they share their information with us, which we then compare with information that is available to us. In this way, we all know what cancer-directed and supportive treatments patients are receiving, and which patients had complications, were seen in the office or went to the emergency department, or needed to be admitted to the hospital.
We have found that many times, patients who are seen in the emergency department could have received proper treatment outside of that setting, but they do not call the office when they have a problem. So, we are changing the protocols to have nurses remind patients regularly of the importance of calling the office. It is a labor-intensive process, but one that we are passionate about and that we believe will reap benefits for patients. We need to be sure it does not look like the plan is interfering with patients obtaining emergency services, so we may need to revise it further.
AVBCC: What other approaches at WellPoint are you taking to lower costs and not compromise quality?
Dr Malin: In addition to our oncology medical home and our new web-based tools implemented to expedite preauthorization (Figure), we are also exploring ways to reimburse oncologists for the time they spend planning treatment and coordinating care using the newly approved S code linked to preauthorization for episodes of care. Over time, we will link this reimbursement to performance as well.
AVBCC: How will you structure your performance measures?
Dr Malin: Performance will be measured by adherence to evidence-based care, selection of treatment options that are value conscious, and quality of care. For this, we are working out the exact metrics, but they will be based on national standards such as the American Society of Clinical Oncology’s Quality Oncology Practice Initiative and the National Quality Forum’s quality measures.
AVBCC: When do you expect stakeholders will agree on what is the best care for a patient with cancer? There are many ways to approach this, and there are many outcomes to consider. How will all of this come together?
Dr Malin: In general, there is pretty good consensus on what the right care is when the evidence is strong. The area where there tends to be disagreement, especially in the context of value, is the use of technology, especially high-cost technology, ahead of the evidence. We want to make sure that our health plan members have access to those technologies that have the potential to improve their quality of life. But we cannot provide patient-centered care if all healthcare dollars go to technology, especially expensive treatments that do not provide a meaningful improvement in patient outcomes, and leave nothing to compensate the dedicated clinicians who are there holding the hands of patients and their loved ones and standing beside them on this difficult journey. That means that we, as oncologists, need to rely on evidence-based medicine and continually refer to its efficacy, its latest progress, and the quality improvements it affords our members.
