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Enhanced Reimbursement for Oncology Services Pays for Patient-Centered Care

August 2015 Vol 8, Special Issue: Payers' Perspectives in Oncology

Payment models that align reimbursement to support treatment planning and care coordination encourage oncology care providers to adhere to cancer treatment pathways, said Jennifer Malin, MD, PhD, Staff Vice President for Clinical Strategy, Anthem, Thousand Oaks, CA, at ASCO 2015.

Anthem has the Cancer Care Qual­ity Program, which aligns the practice patterns of physicians through enhanced reimbursement mechanisms. The providers qualify for enhanced reimbursement by adhering to a treatment regimen that is part of an evidence-based cancer treatment pathway.

“Oncology practices today provide a whole range of services for patients, and typically that has been paid for by most payers out of the margin on the drugs,” said Dr Malin. “We started this program to shift the reimbursement towards more of a value-based reimbursement, so oncologists receive $350 per member per month when they are on a pathway. It’s basically an alternate way of paying for the care coordination and treatment planning that they are already doing, but paying for it directly rather than through drug margins.”

The pathways are available on the Anthem website, and include regimens for various cancers that are included in national guidelines. The pathways include 7 treatment options proved to be effective and cost-effective.

“In order to receive enhanced reimbursement, the oncologist has to select for one of our members one of those regimens that is on the pathway,” said Dr Malin. “This would last as long as their treatment regimen lasts.”

Practices register members with the Anthem Cancer Care Quality Program by entering data into a web-based platform that is operated by an Anthem subsidiary, AIM Specialty Health, and submit data on key clinical parameters, including cancer stage; pathology; biomarkers; planned treatment regimens; performance status; and height, weight, and body mass index.

Overall, 10 Anthem health plan states are active in the program. An integrated database of claims captured from 6 participating commercial health plans and clinical data captured from participating practices and patients registered under the program were assessed. Altogether, 616 practices registered 5538 patients in the program between July 2014 and December 2014. The mean number of patients per practice was 8.7.

The most common cancer types were breast (29% of all registered regimens), lung (15%), colorectal (13%), and lymphoma (10%).

“The goal of the program is to improve the quality of care for our members by decreasing the unwarranted variation [in care] and getting effective treatments, but also to prove value for our members, because when there are different regimens available that are equally effective but cost different amounts, the pathway includes the most cost-effective regimen,” Dr Malin said.

Based on chemotherapy claims for members incurred only from September 2014 through October 2014, 64% of members (N = 2989) were registered with the program. Among registered patients, pathway adherence was 63% for breast cancer, 72% for colorectal cancer, and 63% for non–small-cell lung cancer.

“Our estimate through claims review prior to the program was that 40% to 50% of our patients were being treated according to pathway, and the data through the program show, for the first 3 cancers, we came out with 63% to 74%,” Dr Malin said.

Most requests for therapy were delivered within 2 weeks of submission for review. Within the first month, 75% of requests for breast cancer treatment, 78% of requests for colorectal cancer treatment, and 73% of requests for lung cancer treatment were delivered.

KRAS biomarkers were available for 40% of patients with colorectal cancer, and EGFR biomarkers were available for 19% of patients with lung cancer.

There are a lot of different reimbursement models out there that all involve shifting away from paying for drug margins to paying for more of a monthly management fee,” said Dr Malin. “Each one has approached it slightly different, but I think we will see more of a payment directly for the care and not have the payment tied to drugs.”

Stakeholder Perspective
Last modified: August 30, 2021