Aetna expert explores new cancer payment methodology

November 29, 2015

Insurers like Aetna are implementing payment models for hematologic conditions.

New payment models that were initially developed for primary care or common surgical procedures are now being developed and used for patients with blood diseases.

KolodziejMichael A. Kolodziej, MD, national medical director, oncology solutions, office of the chief medical officer, Aetna, will address some of the challenges of creating payment models for hematologic conditions, review data on hematologic services utilization, and evaluate how insurers are implementing these models, at the American Society of Hematology (ASH) meeting in Orlando, Florida.

During his session “Approach of Insurers to New Cancer Payment Methodology” on December 6 at the ASH Practice Partnership Lunch, Kolodziej will give payers a general overview of what is motivating change in the payer world and how payers are responding, with a focus on what Aetna is doing.

“I will speak to the use of evidence-based treatment pathways and clinical care delivery reform models, such as the oncology medical home,” he says. “I plan to explain how what is happening now is transitional, with the knowledge and experience gained ultimately leading to episode-based reimbursement. I will also address some of the challenges including how to measure and reward quality, and how to account for innovation with its attendant price tag.”

Before he delivered his presentation, Managed Healthcare Executive (MHE) conducted a Q&A session with Kolodziej.

MHE: What is currently happening in the cancer payment landscape?

Kolodziej: The most exciting thing, and a huge catalyst for change, is the Center for Medicare and Medicaid Innovation Oncology Care Model [OCM]. For most oncologists, more than half their business is Medicare. Under the OCM, practices will enter into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients. So it really makes a lot of sense for the commercial payers to attempt to harmonize with Medicare’s program, because it enhances the likelihood of success at the practice level. And of course [at Aetna], we had been working on implementing evidence-based treatment and a medical home delivery model. The pathways piece has been picked up by a number of other payers and because of the patient-centered medical home in oncology research done by John D. Sprandio, MD, and Barbara L. McAneny, MD, there is a lot of interest in the medical home.

MHE: Why is this important?

Kolodziej: We are seeing unprecedented innovation in cancer care, it is a time of great excitement. But innovation is expensive. Everyone is concerned about the high cost of new drugs. Our focus needs to be, “How do we get the best possible patient experience and the best possible patient outcome?” We are also entering unprecedented times of healthcare consumerism and new delivery models. Cancer care can be the test tube, the model for how healthcare reform can achieve the Triple Aim.

 

Next:What have been the challenges for payers in this area?

 

MHE: What have been the challenges for payers in this area?

Kolodziej: Historically, there have been several. First, a lot of the payers haven’t had oncology expertise in house. Second, they have been a little anxious about sensitivities regarding managing cancer. Third, many physicians haven’t been prepared to have a collaborative dialogue around reform. Fourth, the analytics-measuring and reporting-had not been adequately developed. And finally, cancer just isn’t that common in the commercially insured population. But the cost of care has gone through the roof, and doctors are interested in finding ways to collaborate with payers, so the stars are aligned.

MHE: What’s your advice for payers in regard to cancer payment methodology?

Kolodziej: Collaboration with oncologists is key. Developing analytic capabilities that allow measuring the impact of these programs is vital. Keep patients at the center of your efforts. Quality matters. And finally, not everyone is perfect coming out of the gate. Process improvement should lead to better value-driven patient-centric care.

MHE: What does the future hold?

Kolodziej: Change. More survivors. Hopefully more satisfied consumers. Accountability.