Skip Navigation LinksHome > Blogs > Practice Matters
Practice Matters
News about health policy and practice management issues of importance to oncologists
Thursday, September 03, 2015

Several years ago, I asked a Blue Cross and Blue Shield insurance executive why there was so much bad blood between oncologists and insurers, and he said something to the effect of “I’ll start trusting oncologists when they stop administering chemo to patients as they’re on the way to the morgue.”

 That conversation came to mind when Jennifer Malin, MD, a medical oncologist and Staff Vice President for Clinical Strategy at Anthem, explained the company’s Cancer Care Quality Program to me. Anthem operates Blues plans in 14 states, making it one the nation’s largest insurers. And it recently announced a plan to acquire Cigna; if that goes through as planned, Anthem will cover 53 million lives by next year.


Instead of criticizing oncologists, though, Anthem is using payment reform, data-sharing, and a “we’re all in this together” attitude to encourage oncologists to improve the quality and lower the cost of the care they provide.


The basic payment reform Anthem is using is a financial incentive to encourage the use of cancer care pathways. The pathways for nearly 20 different types of cancer are posted online.


Here’s what I learned from our conversation:


Anthem’s payment reform initiative is called the Cancer Care Quality Program. How does this work?

Jen Malin:  “When oncologists register their patients who are Anthem members with the program, they have the option of selecting a regimen that’s on a treatment pathway. When the treatment is on pathway, they are then eligible to submit a claim for additional reimbursement for treatment planning and care coordination of $350 per month.


“In addition to encouraging best practices through the use of pathways that are selected for being the most effective regimens with the best toxicity profile and the most cost-effective, the program will soon be providing data back to practices on their adherence to pathways and on some measures to help them evaluate how well they are doing in other areas of the practice and opportunities to improve care. Those include emergency room utilization and hospitalization for patients on treatment, as well as hospice use and admission to the intensive care unit at the end of life, which are two National Quality Forum-endorsed measures.”


Is this program available in all the states that Anthem operates in? Is it optional for oncologists—or mandatory if a physician wants to be in Anthem’s network?  

“As of September 1, it is up and running in all 14 Anthem states, across all lines of business except Medicaid. That means it is available for fully-insured, self-insured, and Medicare Advantage members in all of our states.


“The program is optional from the standpoint that oncologists never have to select a pathway regimen, and in fact, we expect that there’s always going to be a good reason not to use a pathway treatment option in somewhere between 10 and 20 percent of cases. It is also optional to submit the claim without codes, and no one has to bill for it. So those two pieces are definitely optional.


“One of the ways that the program decreases the administrative burden is that Aim Specialty Health administers the program for Anthem. We have incorporated our prior-authorization requirements for drugs into the same operating system and process. So it is still a requirement to register the patient if the drug requires prior authorization; in those situations, it’s mandatory for practices in our network.”


How did Anthem decide on this program—as opposed to the oncology medical home and some of the other payment innovations that we are seeing around the country?

“There are a number of different efforts going on around the country, as you mentioned. The oncology medical home generally focuses on three areas:

·        Pathways;

·        Improving patient access to the practice so they can have better symptom management; 

·        Improving palliative care.


“We are focusing on all three of those areas in terms of the quality aspects of the program, but the payment reform is currently tied to pathways. The reason is that we wanted this to be scalable across all of our in-network practices. I think most of the other models that have been implemented have generally required contract amendments, and not all practices have necessarily had the resources to be able to participate. We wanted to make our program something that any practice could participate in – the large groups as well as the one- and two-person practices.


“So this does not require a practice to have an electronic health record or any special technology. Regardless of where your practice is on the continuum of transforming and becoming an oncology medical home or a value-based practice, this provides you the opportunity to participate. It provides you additional resources for treatment planning and care coordination. And when you get your data from us, you will be able to start to focus on other aspects of changing your practice.”


How is the Cancer Care Quality Program working out so far? Can you tell whether it is improving patient care? Lowering your costs of care?

“Really important questions. We are just finishing the launch of the program in all 14 states so we have been in implementation mode this year in terms of adding regions and pathways. That being said, we are very enthusiastic because it does appear that most oncologists in our network are registering most of their patients.


“We have data on about 70 percent of the patients in our network who are starting chemo. It appears that, when a pathway is available, practices are selecting a pathway regimen, on average, between 60 and 65 percent of the time. We don’t have really good baseline data since we didn’t collect data before this program was in place.


“From our claims data, we are estimating that, prior to the program starting, practices were selecting regimens that would be considered on pathway about 40 to 50 percent of the time. So we think that there is a signal that there’s greater pathway adherence, which we think is a positive sign for improving the quality of care.


“In terms of the cost of care, we won’t have all the data for at least another year to year and a half. We do anticipate that in the next nine months or so, we should be able to start to look at other important outcomes, like hospitalizations during treatment. That is one important outcome that we think will be improved on pathways since those regimens are specifically selected to have better toxicity profiles.”


Will Anthem participate in the Oncology Care Model being launched by the Centers for Medicare and Medicaid Innovation (CMMI)?

“We did submit an application to be a payer partner with CMMI. We will not be adopting the model proposed by CMS, but we will proceed with our own model. We wrote letters of support for about 30 practices in our network that applied to participate. So once we hear which practices were selected, if CMS does want to work with Anthem and selects us as a partner, then there will be a memorandum of understanding that would be executed between Anthem and CMS, and we would work out ways to collaborate together, certainly on data sharing and using the same metrics and working together.


“We think this may provide a good opportunity for us to go beyond our model with that group of practices that is selected to participate with CMMI and give us the opportunity to test out some new innovations and pilot them with those groups.”


The American Society of Clinical Oncology has proposed its own payment reform model called Patient-Centered Oncology Payment. What do you think about that proposal?

 “I’ve had the opportunity to review the proposal. I think it’s starting to move things in the direction that we all want to go, which is to really to think about paying more for the care that’s delivered to a patient, rather than specifically for a different chemo drug or different things that are done to patients.


“What’s really important to us as a payer is to have a system that is scalable and simple to implement within the current existing claims platform. That’s one of the big challenges with payment reform: We all want to change how services are paid for, but we are still stuck with the same type of codes and claims platforms we have had for years. Within the current existing claims platforms, it did not seem to us that the ASCO model would be that feasible for us to operationalize.”


Oncology practices are seeing many payment reform ideas. Do you expect that this will all shake out so that eventually there will be one payment model that all payers use to pay for cancer care? Or should practices expect to live with a great deal of variation in the way they get paid for the foreseeable future?

“I think payers all recognize that it’s important for practices to have enough consistency that they are not trying to do different things for different payers. That being said, in a free market system, none of us can openly communicate about how we pay for care. We can’t share prices, we can’t share contracts. So there’s a certain amount of variation that’s always going to exist in the current environment.


“But I do think there is definitely a recognition among all the payers that we need to have consistent approaches to measuring quality and value. And AHIP – America’s Health Insurance Plans – has been leading an effort that includes many private payers, as well as CMS. And it is including input from ASCO to try to help harmonize some of these issues.


What do you want oncologists and practice managers to know about Anthem’s plans for payment reform?

“I want them to know that this is a dynamic process. We just launched the program. It took us a little over a year to get it fully launched. We are open to and hope to receive feedback from practices. Anyone can provide feedback on the program by going to our website. The web address is; and the email address is


“We really want this to be a dialogue and to learn from practices as they improve care. What are the best practices, and how can we spread those across our network so that all of our members can benefit?”


Listen to a podcast of the conversation in OT's 10/10/15 iPad issue.



Wednesday, August 26, 2015



Costs of Care is publishing some of the stories entered into its annual story contest, and it’s not surprising to see cancer get a star turn.


That organization, a nonprofit that works to deflate medical bills, has been collecting stories from patients and caregivers for years. The contest doesn’t have categories, but entries could easily be grouped into three piles: frustrating, inspiring, and heartbreaking.


In the heartbreaking category, Holly Woodcock, a nurse in Idaho, tells what happened after she was diagnosed with colorectal cancer in November 2009. Although she had good insurance, her diagnosis took its toll in the form of out-of-pocket costs and missed work days.


“It ate through my sick leave and savings quickly,” Woodcock wrote. “I’d look at the explanation of benefits every month, astonished and overwhelmed that chemotherapy could actually cost $75,000 a month or that one shot to keep my white blood cell count up could cost $7,000 and I needed two every month… When the end of chemo came in 2010, I was well over $35,000 in the red – all from stupid cancer.”


And she is luckier than some of her friends hit by cancer-related costs: One who was treated for cancer lost his business and his home, and one who lost his wife to cancer filed for bankruptcy because of her medical bills and now lives with his mother.


“I’ve sat my husband down and told him … if this cancer returns, I’m not treating it,” Woodcock said. “I refuse to leave him bankrupt.”


Costs of Care Executive Director Neel Shah, MD, an obstetrician-gynecologist at Beth Israel Deaconess Medical Center, and the rest of the team are now looking for a different kind of story. Earlier this month, they announced a new national story contest called “The Best Care, The Lowest Cost: One Idea at a Time.”


The contest, in partnership with the Healthcare Financial Management Association, Yale New Haven Health System, and Strata Decision Technology, seeks to collect and “open source” ideas that help create a healthcare system that delivers value.


“While skyrocketing healthcare costs have many drivers, we believe bringing together shared insights from both clinical and financial leaders is a critical element of making care affordable,” Shah wrote in a blog post. “We are calling upon clinicians, administrators, and patients to submit essays and videos about experiences and ideas that reduce unnecessary cost while providing better care for individuals and families. “


The contest is accepting submissions through Sept. 28 -- and there are cash prizes. To learn more, there’s a 30-minute webinar set for 12 noon ET, this Friday (Aug. 28). 

Saturday, August 01, 2015

 Bruce Pyenson, FSA, MAAA, a principal at Milliman in New York, looks at the business of cancer care through the lens of his work as a consulting actuary. As he scans the payment reform landscape, his attention is riveted on the Centers for Medicare & Medicaid Services and its plans for the Oncology Care Model (OCM).


The OCM will kick off next year as a voluntary program limited to a relatively small number of practices—and they will receive what he calls a generous incentive--$160 per patient per month for six months plus the potential for shared savings—with no downside financial risk.


He sees this as Medicare’s first step toward making oncologists financially responsible for the quality and cost of the care they provide.


“I suspect that Medicare has decided there’s a lot of room to improve in what it is paying for oncology care,” he said in an interview. “One of Medicare’s overall goals is to reduce spending. The take-home for oncology practice is to be flexible enough to adapt to whatever programs Medicare will be launching.”


Which of the new cancer-specific models do you think hold the most promise?  

Bruce Pyenson:  “Medicare’s announcement about the Oncology Care Model certainly has shaken the landscape. Medicare is perhaps the world’s largest health insurance company, and in recent years, it has piloted various payment reform models and then fairly quickly implemented them on a bigger scale. The program they have announced for oncology care is on a voluntary basis--currently.


“There are certainly other models for alternate payment structures being tried on a small scale by other payers, but because Medicare is such a big payer, other payers will look at what Medicare is doing rather than inventing their own system.


“The payment proposal from the American Society of Clinical Oncology is complex, so it might need simplification if it’s going to compete against Medicare’s OCM.”



The accountable care organization (ACO) is one new delivery and payment model that has really caught on with private insurers, and the government continues to push its Medicare ACO programs, which have had mixed results. What are the implications for cancer care if the ACO movement continues to gather steam?

“An accountable care organization is a provider-based organization that, in some form, contracts to accept financial risk for the quality or cost results that it produces. An ACO’s contract with a payer can be set up in many different ways. For example, providers might get upside-only risk or they might get quality bonuses for good clinical performance. Upside-only--an opportunity to receive extra money for good performance--is often how risk contracts begin. But most observers think that accountable care organizations will be taking more substantial financial risk in the future—both upside and downside. The payer’s goal is to deliver high quality at a low cost to the payer.


“The big discussion in accountable care has been around primary care, because primary care providers are potentially the gatekeepers for other care that people receive and also because  primary care can play the coordinator role. However, oncology is an important cost driver, especially for the Medicare population. Although oncologists do not have the control or oversight over the full spectrum of care that their patients get, oncology is associated with so many healthcare dollars that it is a very important component.


“So far, oncologists are not very visible and may not even be at the table in accountable care discussions. But delivering high-quality, cost-effective care is going to be an important issue for oncologists as accountable care evolves.”



You have called this “the era of provider risk.” What types of cancer care practices will succeed in an era of provider risk--and which are the most vulnerable?

"If the new payment models gain traction, practices that are more efficient at delivering care are the practices that will succeed. Efficient care includes not just the care delivered by medical oncologists, but the care that they might influence such as radiation oncology or side-effect management.



Independent oncology practices are less expensive for chemotherapy than hospital outpatient departments. Most payment reform initiatives are trying to lower the costs of care to the payers, whether they are private insurers or the government. Does this mean that independent oncology practices will be favored in payment reform proposals?

“Care delivered at community oncology practices currently is less expensive than hospital outpatient practices for a variety of reasons, and payers of course prefer the less expensive sites. However, there seems to be a lot of interest in “cost neutrality”—where fee schedules do not differ by site of service. That topic is getting a lot of attention from the Medicare program, but many ACOs may also be motivated to remove the cost differential between their community practices and their hospital outpatient practices—after all, under risk arrangements, the ACO may be responsible for the costs.”



What should oncology practices be doing to position themselves for success in this time of payment reform experimentation?

“If practices have enough volume that they can afford to assign someone to watch what’s happening in their community—in  their medical neighborhood, if you will—and what is happening with payers, that would be a good thing to do as part of managing the business.


“They need to look at the opportunities for new payment models. All of them take a significant amount of time and intellectual resources to figure out, and some financial sophistication to think through the consequences and scenarios. Risk is actuarial, and organizations need actuarial expertise.


The world is certainly changing, and practices, whether bigger or small, need to become educated about the different payment models.


“One important thing is to not automatically reject innovative models that require changes to the practice. The normal tendency for successful practices is to say ‘Well, why change? Why do anything?’ However, the fast pace of change and the scale of change suggest to me that few organizations will be unaffected.


Medicare’s Oncology Care Model seems to be very low risk for oncologists and has a potentially large upside, but it may require most practices to make some substantial changes. The right question for oncology practices might be ‘How?’ and ‘When?’ rather than ‘Whether?’ The new payment models are a gateway to the future.”

Monday, June 29, 2015

People frequently use the term “unique” when they mean “unusual” or just “I think this is noteworthy even though lots of other people are doing the same thing.”


But when Larry Strieff, MD, used the term “unique” to describe Hill Physicians Medical Group’s (HPMG) payment innovation for cancer care, I think he was using the term correctly.


Strieff is Oncology Chief for HPMG, the largest independent practice association (IPA) in northern California, with more than 3,800 physicians serving more than 300,000 patients.


An IPA is a group of independent physician practices that jointly negotiate contracts with insurers; in Hill Physicians’ case, the IPA receives a flat per-member, per-month fee in exchange for providing all the outpatient services for a population of patients. The IPA then pays the individual physician groups for their work. Thus, the IPA benefits financially if its physician groups curtail unnecessary expenses.


For the last five years, a subset of HPMG’s oncology practices have been experimenting with a bundled payment arrangement they call the Oncology Case Rate, and most of its other practices are clamoring to join. The reason: The Oncology Case Rate has incentivized participating groups to sharply reduce costs while increasing the quality of care and patient satisfaction—and increasing the payouts to physician groups by 11 percent, compared with the physician groups that do not use the Oncology Case Rate model.


To earn the quality management fee, practices must:

·        Perform well on the Quality Oncology Practice Initiative measures collected by the American Society of Clinical Oncology;

·        Decrease their patients’ hospitalizations and emergency room use;

·        Use less expensive drugs; and

·        Improve patient satisfaction.


Key is How the Bundle of Care is Defined

All those goals are pretty standard in the cancer care payment experiments we are seeing around the country. The thing that make HPMG’s innovation unusual—and perhaps truly unique—is how the “bundle” of care is defined. The case rate is based on anatomical site, not stratified by stage; thus, the site of the origin of the cancer places the patient into a cohort and the application of parenteral chemotherapy starts the case rate for that particular patient. And the period of care stretches for three years, which is much longer than most bundled payments for oncology.


“That’s swimming upstream, and everyone we spoke to said it isn’t going to work,” Strieff said. “All I can tell you is we have almost six years’ experience and the data that would suggest it’s working for us.”


In a recent interview, Strieff, who practices at Epic Care, a large cancer practice in the East Bay area, told me about the experience with the Oncology Case Rate so far.


How did you come to develop the Oncology Case Rate concept? When did you start using it? And how is it working out so far?

Larry Strieff:  “We began looking at ways to control our oncology costs in 2008 and 2009. We were feeling the same economic pressures as others in the health care arena—that is, an escalating spend pattern in the range of 15 to 20 percent per year. That was a clearly unsustainable trend. We then examined our own experience within our network, and we found the primary driver of those increasing costs was the rapid adoption and widespread use of very costly parenteral oncolytic drugs. We also recognized that we were simultaneously facing two realities: The first was a finite amount of financial resources, and the second was there was an explosion in the area of basic research in the area of genomics and submolecular description of the genetic alterations in the human genome that are causally connected to the development of malignant disease.


“This unparalleled development of knowledge in the area led to a virtual arms race among the drug companies to produce more effective and more specific biological and targeted agents. These drugs and these agents held great promise of benefit for our patients, but they were, without exception, very expensive.


“At the same time, it struck us as quite obvious that we were trying to manage these two 21st century realities with a 20th century billing and payment system that was based on the old ‘buy-and-build’ paradigm--that is, my practice would buy the drugs and then sell it to the patient. This, unfortunately, led to a chasing of the profit margin across the spectrum of care that was associated with these new agents. These new agents were both expensive and had a large profit margin. So this old payment system had led inadvertently to an undesirable practice pattern that was rewarding the selling of the drugs over cognitive services of the doctor.


“These cognitive services had always rewarded clinical judgment, skillful patient management, and analytical thinking versus the selling of drugs. We tried to develop a system that would enable the doctors to move away from the buy-and-build mode of practice and to return to the more desirable functions of delivering cognitive services.


“So we launched the program in early 2010 with the initial practice in Sacramento and added a second practice in 2011 in the East Bay Area of San Francisco. At this point we have a little more than five years’ experience with the first practice.”


How does the Oncology Case Rate work?

“This is based on the placement of patients into groups, or cohorts, based on the anatomical site of the primary tumor. For instance, the breast cancer patient would be in the breast cohort. The reimbursement for the care of these patients is paid monthly, and it’s based on our previous three years of financial experience for patients in that cohort, treated within our network with oncolytic therapy. We know from our data what the chronological spend pattern for each diagnostic cohort is, and the payment is structured accordingly.


“There is a unique and quite controversial aspect to our program, which is the manner in which patients are allocated to the cohorts. We allocate on the basis of the anatomical site of the tumor, and whether or not patients have received parenteral chemotherapy. We specifically do not stratify or place patients in cohorts based on the stage of disease or cell type, age, or comorbid status. This is a departure from what almost every other bundled payment program uses as methodology, and actually represents a type of population management.


“Another aspect of our system is that we pay, not the individual doctor, but rather his or her group. This helped to smooth out the statistical risk of an occasional outlier, and at the same time, helps to foster what we term ‘intragroup monitoring’ for best practices.


“An additional aspect we think is unique, at least in our experience, is that we have included a stop-loss provision. This is placed to protect the doctor group from unexpected expense associated with an exceptionally expensive patient, and it avoids the doctors from being financially penalized in doing the right thing at the right time. This avoids the prospect of an expensive outlier patient causing undue financial hardship on the practice.


“The last aspect, or building block, of this program is what we call our quality management program. We survey the practices for three sets of quality measures. The first is the clinical scores on the ASCO QOPI guideline measures. A second area we examine for practice pattern is in the utilization of inpatient services, emergency department and infusion centers. And the third is we survey the practice scores on patient and physician satisfaction.


“This latter part of the program—this quality management program—constitutes 10 percent of the total reimbursement to the doctor, so it has proved to be a very significant agent for change in practice patterns.”


What impact has the Oncology Case Rate payment model had on quality measures? On patient satisfaction? On patient outcomes?

“As I mentioned earlier, we do measure the clinical quality metrics using the QOPI guidelines, and our scores on the QOPI guidelines for our practices are now 98 percent. That’s both self-reported and by chart review confirmation here at Hill Physicians headquarters.


“The utilization on the inpatient side has decreased by 14 percent. We’ve seen no increase in the use of infusion centers. The patient satisfaction remains at over 90 percent.


“Our physician satisfaction metric is a little different from what people might anticipate. We are actually measuring the satisfaction of the referring doctors to the oncologist. The most common complaint patients have in managed care is: ‘My doctor doesn’t talk to my other doctor.’ So we do make sure of the effectiveness of my communication with my colleagues who refer patients to me. We believe that the issue of poor communication represents suboptimal care, so we think that particular measurement is an important one.


“We have also examined our survival figures over the last five years, and they are at least the same—and in some cases slightly better—than those for our oncologists who are in our network and being paid on the fee-for-service basis.”


How has the Oncology Case Rate worked out financially for your practice?

“To answer your question, we decided to look at the financial performance of the fee-for-service practices in our network—because only half of our oncology patients are taken care of on the oncology case rate—and compare that with the financial performance for the groups who are in the case rate. Our most recent data shows that there is a positive yield of more than 11 percent for those practices in the case rate, as compared with their competition in the fee-for-service side.”


Do you think the Oncology Case Rate should be the future of cancer care payment? Why or why not?

“It’s my belief that some form of bundled payment will be the future of oncology going forward. I think that we will have different iterations of bundled payment, depending on local needs and opportunities, and I don’t think that one bundled payment system will necessarily work for everyone across the country. But I do think some variation on a bundled payment, such as a case rate, will be the future.


“I think that the future is going to require adaptation to other needs, including the inclusion of oral drugs, or Medicaid patients, or possibly including combinations of medical oncologists plus radiation oncologists, plus surgeons, and eventually other partners. So I think the approach of a bundled payment system has the most flexibility of any program that I’ve seen so far. Hill Physicians is looking at all of those possible scenarios as we go forward.”




Listen to a podcast of our conversation in OT's July 25 iPad issue.

Monday, June 22, 2015

If I were a cancer drug manufacturer, my palms would be sweating.


The American Society of Clinical Oncology today announced its idea for helping physicians and patients think about the value of new cancer treatments compared with the current standard of care.


ASCO’s “Value Framework” for evaluating new therapies by simultaneously evaluating three elements—clinical benefit, side effects and costs—was published today in the Journal of Clinical Oncology. 


ASCO’s Value in Cancer Care Task Force developed a way to compare those three elements for treatment regimens that been tested head-to-head in randomized clinical trials. The clinical benefits and side effects of each regimen are used to calculate a “net health benefit” score that represents the added benefit of a new therapy in comparison to the standard of care.


The goal is to provide a tool that physicians and patients can use to consider whether the toxicity and cost of a new treatment is a good tradeoff for an improved benefit, as measured by overall survival or progression-free survival. Because patients’ differ, not everyone will assess value in exactly the same way.


“It’s critical to distinguish between value and cost,” Task Force Chair Lowell Schnipper, MD, said in a news release.  “Sometimes the more valuable treatment will be the more expensive one and sometimes it won’t be. Ultimately, the definition of ‘value’ will be highly personalized for each patient, taking into account an individual’s own preferences and circumstances. For example, in the setting of advanced cancer, is length of life the most important goal or is quality of life? Is the proposed treatment affordable? That’s why we’re proposing to provide information on net health benefit and cost side-by-side.”


While the Value Framework will absolutely facilitate shared decision-making conversations between oncologists and their patients, it will also shine some hard light on expensive new treatments. Two of the four examples given in the JCO article show that the newer, more expensive treatment offers no net health benefit.


Does the Task Force have it right? ASCO is seeking feedback on its concept through Aug. 21. I am so curious to hear what you think -- Leave a comment to let me know!

About the Author

Lola Butcher
LOLA BUTCHER, MPA, MA, an award-winning Contributing Writer for Oncology Times, writes about health policy and business trends. She is a frequent contributor to Hospitals & Health Networks, Modern Physician, Neurology Today, and other health care trade publications. This blog was recently recognized with an APEX Award for Publication Excellence.