WellPoint and UnitedHealthcare are among private payers that have been testing new models to improve patient outcomes and lower costs, even before the Centers for Medicare and Medicaid Services released rules around new payment and care delivery approaches.
WellPoint plans are involved in several multi-payer medical home pilot programs, while UnitedHealthcare is working with five medical oncology groups across the country to advance a cancer payment model.
They are among 200 pilots that America's Health Insurance Plan members are participating in around the country to test medical home, bundled payments and accountable care organization models.
UnitedHealthcare's program is aimed at improving the quality of care for patients with breast, colon, and lung cancers. It is designed to reimburse participating oncologists upfront for an entire cancer treatment program, shifting away from fee for service to a bundled or episode payment approach.
Dr. Lee Newcomer, vice president for oncology at UnitedHealthcare, said the payer undertook the pilot because oncology costs were jumping as much as 20 percent annually. Physician administration of chemotherapy is less expensive, more compact and patient friendly than hospital outpatient sites.
"By paying medical oncologists for a patient's total cycle of treatment, rather than the number of visits and the amount of chemotherapy drugs given, the program promotes more patient-centric, evidence-based care with no loss of revenue for the physician," he said at an Oct. 18 AHIP conference.
UnitedHealthcare also wants to identify and reward best practices, "creating a learning environment in which we will continually look at data and improve," he said.
Up to 70 percent of an onocology practice's income is derived from drug administration. UnitedHealthcare incorporates that fact when it negotiates its contracts. For the pilot, the payer wanted to reward evidence-based care and keep oncologists' income at present levels and separate the dependence on drugs as part of the income.
Participating oncologists must comply with an agreed upon treatment regimen for each episode. It's been in place for 18 months with 85 percent compliance.
"Now that we have a group of patients that are being treated consistently across the country, all have agreed to meet annually to compare results, see how the other groups are doing and search for best practices," Newcomer said.
All participants will move to the best practices, which will be based on data from measures for total cost of care per episode, survival rate, time to progression for first regimen in metastatic disease and admissions for uncontrolled pain.
Episode payment categories were created for adjuvant treatment for additional therapies after surgery and metastatic treatment, which will continue for spreading or resistant cancer.
"The episode fee will change when the outcome is better and total cost is down," he said.
Caring for a terminally ill patient is time intensive. "An office visit of $60 doesn't come close to covering the cost of the doctor, but they are free now to make a decision that is not dependent upon that cost," Newcomer said.
WellPoint participates in Colorado's Health Team Works, which includes six major payers, Medicaid, and 15 practices with 60 physicians, who collaborate for better care management, use health IT and align reimbursement methods with improved patient access and outcomes.
"We all believe in medical home, but unless we figure out how to do it successfully and how to scale it we're not going to get there," Dr. Lisa Latts, vice president of public health policy at WellPoint Inc.
In the first year, the pilot achieved improvement in diabetes measures, moderate decreases in inpatient admissions, specialists' visits and medication usage, and a 6 percent drop in emergency room visits.
Most practices do not have the financial capital or human resources to migrate to a medical home on their own. A convening organization facilitated that for the pilot. The first six months were just practice conversion. And these are the early adopters. "The folks that come after are not going to be as easy to convert," she said.
Patient messaging is an important aspect of the medical home. Patients need to be trained to behave differently to take more responsibility for their health.
Care managers are critical to make sure that patients follow through on their treatment and controlling conditions. However, physicians don't want a care manager in their office from each participating plan.
"We have to figure out a way to integrate care managers across all of the health plans doing business with the physician's office," Latts said.
Provider reimbursement comes in three pieces: fee for service; pay for performance based on quality, cost and satisfaction; and care management fees that range from $3.00 to $7.50 per member per month. Figuring out the dollar amount was relatively easy, but how to pay the parts was complex.
WellPoint manually cuts a check to each of the physicians every quarter. "This is not ideal or scalable, and we have to figure out a better way," she said.
What changed in the practice with the medical home model is that patients have improved access to primary care services--click, call or come in, improved communications and meaningful after-hours availability, said Dr. James Meyer, a participating physician at Mountaintop Family Health. Quality improvement became a priority function and with it an awareness of cost.
The multi-payer approach fosters inclusiveness and reduces fragmentation. "We don't have to exclude patients if they change insurance," he said.