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Cancer care: Better results for lower costs

| Jul 07 2014

By Michael Kolodziej, M.D., National Medical Director for Oncology Strategy

We want safe, effective and efficient cancer care for patients, with fewer side effects. Currently, it’s easy to get distracted by conversations about how paying oncologists an additional fee for each patient in their care can promote evidence-based treatment and lower costs. But the reality is that improving cancer care requires a more robust, collaborative approach.

Doctors need real-time tools to help them make informed decisions about evidence-based best practices. They also need information that helps them understand the impact of their decisions on health care quality and costs. Within oncology care, Aetna is working with doctors on a multi-faceted approach to make fundamental changes that are sustainable and create better quality outcomes for patients.

Measuring and Rewarding Change

Changes in payment for oncology care are absolutely necessary. Incentives and risks have to be aligned among doctors and payers and focused on patient outcomes. Aetna has a phased approach that supports change – starting with payment models that support the use of clinical pathways (evidence-based care guidelines) and progresses to patient-centered medical homes for oncology. Quality performance measurement and information sharing are intrinsic to the payment models.

As a first step, oncology practices are eligible to receive enhanced reimbursement for prescribing generics that are proven to be clinically equivalent to more expensive brand drugs. They also are eligible to receive a portion of savings generated if quality metrics are achieved. These quality metrics have typically been 80 percent compliance to clinical pathways. Freedom to provide personalized care is expected and encouraged. While a handful of companies have offered similar clinical decision support tools for several years, Aetna has advanced the approach to implement market-based, payer-agnostic solutions that remove the burden from oncology practices of trying to conform  with multiple and varying payer requirements.

Putting the member first

Aetna helps practices evolve their processes to focus on the patient and provide high quality, evidence-based care. The added benefit: this also can reduce costs. Once practices are comfortable following clinical pathways and measuring their adherence to these guidelines, Aetna works with the practice to actively coordinate patient care within and outside the walls of the practice within a patient-centered medical home model of care. The model includes increased telephonic and in-person outreach, such as talking about side effects early and often. Specialized care management teams become the first point of contact for the patient and the family, and if necessary, offer advance care planning for patients at the end of life. These efforts help reduce emergency room visits and the length of stay for hospitalized patients, but most importantly, they increase patient satisfaction.

Working together to break the box

Aetna has different models to reward practices developing a patient-centered medical home for oncology and for improved performance. In some circumstances, we may pay practices a fee up front to support investment in infrastructure or specific fees aligned to services such as in depth discussion of the treatment plan with the patient. Or, we may include an upside risk arrangement that allows practices to share in savings resulting from more efficient, effective care. This departure from the traditional fee-for-service model supports and rewards patient outcomes, not the number of services or drug selection. Aetna is working with oncologists and patients to make cancer care better. We are only in the middle of our journey and proud to lead the way.