Payment Reform Models in Oncology Care & Management

Monday, February 20, 2017

Authored by Mary Seery
Cancer Treatment Centers of America National Director of Business Markets

With everything going on in the world of politics, policy and health care, I am certain that oncology payment reform is not on the top of your mind – but maybe it should be! Years ago when I began working for a large health care system focused on oncology, I would not have bet (and I am a bettor), that payment reform would so quickly have reached the complex world of oncology – but it has and it should be on your radar. Here’s why:

While Medicare might be the most recognized oncology payment model pilot running nationally, the big commercial payers as well as providers big and small are dipping their toes in the water of understanding how oncology payment reform can reduce cost and improve quality of care for one of the most expensive diseases to treat. Even physician groups and health systems have begun focusing on the topic.

Alternative Payment Models or APMs take many forms, names and claims. They include or can be tied into different delivery models including specialty Accountable Care Organizations (ACOs) and Oncology Medical Homes (OMHs). Most reward the providers for following certain defined pathways that are thought to provide the most effective, least toxic and least costly treatment. While I agree that there is value to this approach in orthopedic and simple cardiac procedures, it certainly gets more difficult with the complex, individualized treatment of cancer. Advancements in precision medicine are beginning to gain traction but remain largely unrecognized in reimbursement approaches. Are these models ready to make room for advancements or will they insist on the reliance of predetermined treatment pathways?

To muddy the waters a bit more, payers and providers alike are piloting episode-based payments and/or bundled pricing for either certain aspects of treatment or all facets of cancer treatment. Speaking from the provider side, my opinion is that this can be a very hard road to maneuver down. It’s a shared risk approach which can be tempered by more prevalent and predictable cancers, but as a former colleague always said to me “every cancer is like a snowflake”.

So the key question today is “are these approaches working?” Some commercial payers are reporting savings, but we are unclear as to whether the savings are built off a loss for the provider. Providers tend to receive only a nominal fee for participation in their programs. That fee can vary from approximately $160 in CMMI’s Oncology Care Model (OCM) to a reported $350/month in a commercial pilot. While this is not an apples to apples comparison of the programs, it just illustrates that payment variation still exists and will continue to exist between government and commercial payers. With MACRA likely decreasing physician reimbursement over the next decade, how will the providers of care fare in the future?

One thing is certain – everything is changing and it will be a race to the finish to see what APMs make the most sense. You, as employers, carry the power to help guide your employees through what works best by being informed and designing their plans to help them get the best care at the appropriate location at the best price for you. I am looking forward to working with you and The Florida Alliance this year on the oncology payment model project.

Mary Seery is the National Director of Business Markets for Cancer Treatment Centers of America (CTCA). She leads the efforts to increase patient access to all CTCA hospitals through direct contracting with employers and insurance networks. She and her team are responsible for leading the development of key national large employer, payer, and influencer relationships as well as health care intermediary and regulatory relationships.

Mary has over 18 years’ experience in healthcare. Prior to joining CTCA, Mary has worked across many regions of the country with some of the largest pharmaceutical companies to commercialize new medications and increase market receptivity and use. Mary directed regional business expansion while with Medical Resources, Inc. She has also led new business marketing and growth through her time as Marketing and Sales Director at Windy City Anesthesia.

Mrs. Seery received her Bachelor of Arts degree in Public Relations from the University of Illinois Chicago. She currently sits of the National Board of Directors for the Association of Corporate Health Risk Management and is a Transparency Committee Member for the Greater Philadelphia Business Coalition on Health. Mary is also a member of the National Health Leadership Council. She also volunteers for her town, the Village of Orland Park, on various Committees and Commissions.

Mary Seery, National Director of Business Markets for Cancer Treatment Centers of America (CTCA) 2/20/2017

Add your comments:

Items in bold indicate required information.

Name :
Email :
Comments :