The trajectory of cancer care is so costly and problematic that insurers are flocking in droves to the federal government's multi-payer alignment experiment.
The Centers for Medicare & Medicaid Services' Oncology Care Model has attracted 42 insurers large and small who want to try out the hybrid, value-based approach in commercial, large group, Medicare and Medicaid health plans. (See the full list below.)
CMS set up the program for Medicare and has received applications from 443 independent and health system-owned oncology practices who want to participate. The interest from so many health insurers, including Aetna, Anthem, UPMC Health Plan and many Blues, suggests that the program has a lot of potential to shape the experience and outcomes for millions of Americans with cancer, and national cost burden. U.S. cancer therapy costs stood at $124.6 billion in 2010 and could reach as much as $207 billion by 2020, according to National Cancer Institute estimates.
The Oncology Care Model has a two-part system for paying oncology practices. One is a monthly per-beneficiary payment of $160 for clinically managing cancer patients during a 6-month care episode, with the potential for outcomes-linked chemotherapy payments.
The other part of the model is a list of six services and conditions the medical practices must meet. These include offering "core functions of patient navigation," 24/7 patient access to "an appropriate clinician," and a care plan covering the Institute of Medicine's 13 quality factors.
The other conditions include broad stipulations that medical practices provide "therapies consistent with nationally recognized clinical guidelines" and "use data to drive continuous quality improvement." Also, by the end of the five year demonstration, the medical practices must be using a federally-certified electronic health record that has met the rigors of the health IT meaningful use program's second phase.
CMS encouraged other insurers to participate in "alignment with Medicare to create broader incentives for care transformation at the physician practice level," the agency said. "Other payers would also benefit from savings, better outcomes for their beneficiaries, and information gathered about care quality. Payers who participate will have the flexibility to design their own payment incentives to support their beneficiaries, while aligning with goals for care improvement and cost reduction."
18 million U.S. cancer survivors expected by 2012: IOM.
Many of the 443 medical practices that applied to participate will do so with Medicare, and the 42 insurers are recruiting a mix of docs and organizations from their networks, which may include providers hoping to work with CMS as well.
How flexible the design for private payers will be remains to be seen. It's an open question whether too much flexibility ends up being an administrative problem for oncology practices who are looking for simplification in the alignment goal. Another question is whether the model will be able to help reign in $100,000 per month prices for new breakthrough oncology drugs or the costs of many other complex medications.
Forty-two insurers have sent letters of intent to participate in the the multi-payer program. In terms of geography and membership, the Anthem Blues could put the largest stake in the pilot, proposing to adopt the model in commercial and Medicare Advantage plans across its 14 states.
Aetna would be the second largest, proposing to adopt the model in commercial, large group ASO and MA plans in eight states, including Arizona, Florida, Illinois and Texas.
Other insurers looking to participate in multiple states include Humana, in six states, Cigna, in 11 metropolitan areas, and the Cambia Regence Blues in Idaho, Oregon, Utah and Washington.
HCSC's BCBS of Montana, BCBS New Mexico and BCBS Oklahoma are planning to participate with commercial, MA and, in New Mexico, Medicaid managed care plans. The mutual company's largest health insurer, BCBS of Illinois, is not on the list. Also missing from the applicants is UnitedHealthcare, the nation's largest private insurer by membership (and one with its own oncology pilot).
Not every insurer may go through with the demonstration, or at least not on a large scale, depending on how many oncologists in their regions are open to the idea. Blue Cross and Blue Shield of Massachusetts wants to participate in the model with commercial health plans, but has not yet "identified a provider partner," while expecting one to be found at least in the eastern part of the state.
Six provider-sponsored health plans are also participating in commercial, Medicare and Medicaid populations, including Henry Ford Health System's Health Alliance Plan and Priority Health in Michigan, AultCare and SummaCare in Ohio, UPMC Health Plan in western Pennsylvania, and Presbyterian Health Plan in New Mexico.
Multi-payer alignment oncology model: Insurer, plans, proposed markets
Aetna Commercial, ASO, Medicare Advantage, AZ, FL, IL, NY, OH, TN, TX, VA
Anthem Commercial, Medicare Advantage, CA, CO, CT, GA, IN, KY, ME, MO, NH, NV, NY, OH, VA, WI.
Arkansas Blue Cross and Blue Shield Commercial, ASO, Medicare Advantage.
AultCare Corporation Commercial, ASO, Medicare Advantage Ohio.
BCBS Alabama Commercial, Medicare Advantage, Medicaid FFS.
BCBS Arizona Commercial.
BCBS Massachusetts Commericial.
BCBS Michigan Commercial, ASO, Medicare Advantage.
BCBS Montana Commercial, ASO, Medicare Advantage.
BCBS New Mexico Commercial, Medicare Advantage, Medicaid.
BCBS Oklahoma Commercial, ASO, Medicare Advantage.
BCBS South Carolina Commercial.
BCBS of Tennessee Commercial, Medicare Advantage, Medicaid.
Blue Shield of California Commercial, ASO, Medicare Advantage.
Capital BlueCross Commercial, ASO, Medicare Advantage, Central Pennsylvania.
Capital District Physicians' Health Plan Commercial, Medicare Advantage, Medicaid, Greater Albany.
Care1st Health Plan Medicare Advantage, Medicaid, Arizona.
CareOregon Medicare Advantage, Medicaid.
Cigna Commercial, ASO, Metros in AZ, CA, DC, FL, GA, MD, MO, NJ, NY, TX, VA
CrestPoint Health Commercial, Medicare Advantage, Tennessee.
EmblemHealth Commercial, ASO, Medicare Advantage, Medicaid, New York.
Empire BCBS (Anthem) Commercial, ASO, Medicare Advantage, Eastern New York.
Harmony Health Plan (WellCare) Medicare Advantage, Medicaid, Illinois.
Health Alliance Plan Commercial, Medicare Advantage, Greater Detroit.
Health Net of Arizona Commercial, Medicare Advantage, Medicaid, select counties.
Health Net of California Commercial, Medicare Advantage, Medicaid, Southern CA.
Health Partners Plans Medicare Advantage, Medicaid, Greater Philadelphia.
Healthfirst PHSP Medicare Advantage, Medicaid, Greater NYC.
Horizon BCBS New Jersey Commercial, Medicare Advantage.
Humana Commercial, ASO, Medicare Advantage, Medicaid, AZ, FL, IL, OH, TN, TX
PacificSource Commercial, ASO, Medicare Advantage, Medicaid, Oregon.
Piedmont Community HealthCare Commercial, Medicare Advantage, Virginia.
Presbyterian Health Plan Commercial, Medicare Advantage, Medicaid, New Mexico.
Priority Health Commercial, ASO, Medicare Advantage, Medicaid, Michigan.
Regence BCBS Commercial, ASO, Medicare Advantage, Medicaid, ID, OR, UT, WA.
South Carolina DHHS Medicaid managed care, FFS, Dual Eligibles.
SummaCare Commercial, ASO, Medicare Advantage, Ohio.
University of Arizona Health Plans Commercial, Medicare Advantage, Medicaid.
Touchstone Health HMO Medicare Advantage, Greater NYC.
Tufts Health Plan Commercial, Medicare Advantage, Massachusetts.
UCare Commercial, Medicare Advantage, Medicaid, Greater Minneapolis.
UPMC Health Plan Commercial, ASO, Medicare Advantage, Medicaid, Western Pennsylvania.