March 2016 Edition Vol.11, Issue 3

Better Care, Better Payment, and Savings: A Win-Win-Win Approach to Payment Reform

Better Care, Better Payment, and Savings: A Win-Win-Win Approach to Payment Reform (continued)

Skepticism

While an increase in upfront payment is certainly enticing, providers are understandably skeptical about payment reform given the problematic structure of many alternative payment models. Physicians have already been forced to change care to align with Medicare payment systems composed of costly and sometimes ineffectual metrics. There’s also the fear of being held accountable for outcomes outside of their control.

“It’s important to make sure you’ve got the right measures that are focused on things that oncologists can reasonably expect to control,” said Miller, “which is why the ASCO model is focused on specific guidelines already in place.”

According to Miller, payers may find the ASCO payment model attractive because it’s designed to work in ways a health plan can administer. It proposes adding new billing codes for currently unfunded services and adjusting the payment amounts for services that are based on performance measures. Condition-based payments, although ultimately necessary, he said, would be more complicated to implement.

While payers might find bundled payments acceptable or desirable in theory, they may not have the systems needed to implement them in practice. New software systems and programs would have an associated cost. “There needs to be enough consensus that bundled payments are needed in order to make this worthwhile for payers to invest in,” Miller said.

Inevitably, there’s going to be uncertainty on both sides: Can oncology practices meet performance targets, and will savings actually offset higher payments? In order to make this work—to benefit patients and save money for payers in a way that’s feasible—genuine partnerships between oncology practices and payers are essential.

“Oncology practices can’t change the way they deliver care unless payers agree to pay them differently,” Miller said. “Practices will need claims data from the payers to be able to estimate what the potential savings or impact of these changes would be.”

Accountability angle

With direct payment supporting the services they want and need, the biggest win may be for patients. Whereas shared savings models might encourage rationing of care, the ASCO model, driven by appropriate use criteria, prevents both overuse and underuse of medical procedures. There are no rewards for simply spending less (or more) on a patient.

“Holding practices accountable for delivering services that are by definition good for the patient means that patients are more likely to get these services reliably… Better care also means patients aren’t spending what may be the last months of their life sitting in the emergency department.”

In addition to receiving the services that they need, patients no longer have to worry that their physician is somehow being secretly rewarded for spending less on their care, and patients don’t need to spend money on cost-sharing for drugs or tests that they don’t really need, he added.

“If oncologists take accountability for reducing the avoidable services, which drive a significant portion of cancer spending,” said Miller, “then we’ll have financially viable oncology practices that are paid adequately to deliver high-quality care and not put at risk for costs they cannot control. That’s a true win-win-win.”

Conclusion

Despite the turmoil surrounding payment reform, one thing is certain about the future of oncology: lower spending is essential. Payers say they can no longer afford the exorbitant costs of cancer care. But by placing the onus on oncologists to identify what’s needed for high-value care, Miller has broached an elegant solution. Better care for patients, better payment for oncologists, and savings for payers—all at the same time—it almost sounds too good to be true. By giving oncology practices sufficient resources and flexibility to design care that matches patients’ needs, however—and not rewarding them for stinting on care—Miller believes this model can become reality. 

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