New pay model allows physicians to closely manage cancer patients

Troy Parks , News Writer

Two things that physicians want for their patients are more stability and fewer visits to the emergency department. But often the services that are needed to do so are unbillable, and the resources are hard to find otherwise. A new care model for oncologists intends to solve this problem by providing the resources needed to closely manage patients’ care in-between their face-to-face treatments to reduce complications.

The American Society of Clinical Oncology (ASCO) developed the patient-centered oncology payment model, an alternative payment model (APM) that focuses on two things: making sure the patient is taken care of in a way that prevents complications, which helps them progress toward improved overall health, and ensuring physicians have the necessary resources to provide that quality care.

“The current system is flawed in many ways because it doesn’t pay for the services and the support that patients need and want,” said Robin Zon, MD, an oncologist and member of the ASCO’s Oncology Payment Reform and Implementation Workgroups. “But physicians are paying for it in a number of other ways in order to be able to deliver those services to the patient.”

“What’s happened over time,” she said, “is that practices aren’t able to accommodate those expenses to be able to optimally care of the patient. There are services that the patient is receiving and needs, but they’re non-reimbursable services.”

“We developed a system that does three major things,” Dr. Zon said. The model shifts the focus away from typical fee-for-service, holds physicians accountable for high-quality care and makes physicians accountable for only those services they are able to control.

So how does the payment model work, and what kind of difference will it make? Dr. Zon gave an example of a patient we will call John:

Before the new model

Three years ago, before the patient-centered oncology payment model, John would go into a small practice for his chemotherapy. Then he would head home afterwards with instructions to call the office with any concerns or questions. The next day he didn’t feel very good. But he didn’t want to bother the doctor, thinking it was a normal reaction to the chemotherapy or the underlying cancer, so he didn’t call the office. Since this is a small office, there is no extra staff to conduct outbound triage to check on John. Two days later he had severe diarrhea and nausea and ended up so dehydrated that he had to go to the emergency department.

After the new model

Now, John goes into a practice that has implemented the patient-centered oncology model. The next day, an outbound triage nurse calls him at home and asks how he is doing. John says he’s not feeling too great. The nurse says, “Let me talk to the doctor and get back to you.” The nurse calls John again with recommendations from the doctor based on how he is feeling and reeducates him on how to use his supportive care medications.       

The nurse calls again the next day to see if John is feeling any better. John says he’s feeling a little better but not perfect. The nurse responds, “Let me talk to the doctor again.” The next phone call to John includes some adjustments in hydration and diet, as well as recommendations on how to use the supportive medications. In the end, they’re able to help John get through those initial three days, and he never ends up at the hospital.       

“The exciting thing about this model is that the focus really is on the patient, which is why I like the name of the model so much,” she said. “It’s patient-centered, meaning the [payment] supports the resources needed to provide the care the patient needs and wants. This is opposed to the current system of [paying] only for face-to-face visits, which does not care for the patient between these encounters.”

“Our philosophy, from the ASCO perspective,” she said, “is that really what we should be designing is a [payment] system that supports the services that patients need and deserve and want,” not just those that are provided when the patient comes into the practice for a visit or chemotherapy.

ASCO designed a system that has three payment options for oncologists:

Care management payments

This approach takes the existing E/M codes and adds care management codes during an episode of care. An episode of care is defined as a period of time that a patient receives chemotherapy, approximately six months.       

Calculating the total cost for time and resources was the next step. Currently, when physicians see a new patient they are paid X by an E/M code. The amount of time and resources spent in the new patient evaluation and treatment planning is really X plus Y, which is the care management component. But physicians are only paid for X.    

The care management payment would also persist during active treatment and would “help pay for things like outbound triage nurses that check on patients,” Dr. Zon said. “After the active payment period, there would be a short period of continued care management because there is management of the after effects of treatment that do require resources from the office, and [they don’t] require a face to face visit.”      

“Right now, we only get paid for face to face encounters,” she said, “but we do so much more for patients that is beyond face to face and not billable.”

Monthly payments

In this option, there are monthly fees for treatment design and then for active treatment and follow up. The intention is to better support the array of services that are needed when a patient is first diagnosed with cancer and to allow more flexibility in how care is delivered to the patient. The monthly fee would replace the E/M codes with monthly payment codes.     This option would significantly reduce the number of codes required for billing. The doctor is then responsible for allocating the resources in a manner that supports the services required for the patient’s care.      

Bundled payment

A bundled payment is paid to the physician. It includes not only the oncology practice costs but also other costs such as tests, hospitalizations and possibly drugs.     

It is yet to be decided if the bundled payment will be paid ahead of time or after delivery of services.

“It’s important to stress in all three of the options there is a transitioning away from fee-for-service to what we are calling value-based patient-centered care which includes accountability,” Dr. Zon said. “In fact, the model includes providers being measured with regards to delivery of quality care, but only for the services that oncologists can control.”

The big difference between this APM and the Center for Medicare and Medicaid Innovation’s Oncology Care Model is that physicians are only held accountable for the areas they can control, she said. For example, “if the patient has a cardiac event under our APM … that would not be included in our requirements to attest to delivering quality care because we can’t control what the cardiologist thinks is necessary for that patient.”

“Other demonstration projects have actually have shown … that just by providing the money for care management as well as non-face-to-face, non-reimbursable services,” she said, “that you’re able to reduce … some of the biggest cost [drivers] in health care, which is acute hospitalizations.”

ASCO is currently testing the model in several pilot programs and plans to present this model to the Physician-Focused Payment Model Technical Advisory Committee (PTAC)—a committee of experts who will advise CMS on APMs for the new Medicare payment system.

Watch for a podcast interview from ReachMD in the coming weeks with Dr. Zon.

Listen to a podcast interview with Lawrence Kosinski, MD, who discusses his APM, SonarMD. Also, learn about Dr. Kosinski’s APM at AMA Wire®.