Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Claims Management News

Do Provider Reimbursement Pathways Need Oncologist Perspective?

Oncologists will need to have a seat at the table when developing cancer care pathways and a provider reimbursement system that “emphasizes value over volume.”

By Vera Gruessner

- When it comes to oncologists following a set protocol for cancer care, should health payers have a say in the type of pathways these physicians need to follow? An opinion piece from JAMA Oncology seems to say otherwise. The issue at hand is that, in July of 2014, WellPoint began a program in which the insurer would base provider reimbursement to oncologists on whether they adhere to the payer’s cancer care pathways.

Cancer Care Pathways

This means that the future of oncology services may rest on the shoulders of payers instead of allowing physicians to pursue established cancer care pathways that are relevant to all patients rather than the insurers’ decisions. The JAMA Oncology article brings out a number of questions when it comes to the pursuit of cancer care pathways.

First, should payers or providers have final say on creating these pathways? Also, should oncologists be forced to implement a set of cancer care pathways that are unique to each individual payer?

Essentially, it is argued within the article that oncologists should have a final say in what type of protocols are followed when it comes to cancer care. However, there are clear benefits of developing and sticking to these provider reimbursement pathways. For example, Blue Cross Blue Shield uncovered that it saved as much as $30 million by using oncology pathways on patients receiving chemotherapy.

For instance, when it comes to assigning prescription drugs among cancer patients, following these protocols allows for a more streamlined approach within a bundled payment model. It also reduces the need for preauthorization and appeals between providers and payers. However, oncologists who decide to forego a clinical pathway in a particular case may find provider reimbursement more complex.

READ MORE: BCBS of Minn. Cites Risk Pools for $322.4M in 2016 Losses

“When doctors diverge from a clinical pathway, even for well-justified reasons, payers are likely to either deny coverage or require prior authorization, which can delay treatment and threaten patients’ health,” Dr. Robin Zon, chair of the American Society of Clinical Oncology, said in a public statement.

“The sheer number of pathways has created intense administrative burdens because oncology practices are forced to sift through the various requirements and preferences of the pathway program of each payer on a patient-by-patient basis.”

Clinical pathways could prove useful when applying it to new regulations such as the Medicare Access and CHIP Reauthorization Act and the Oncology Care Model established by the Centers for Medicare & Medicaid Services (CMS).

However, before a clinical pathway can be chosen, it is vital to have better defined data based on a patient population, as cancer treatments and our knowledge of the disease itself has grown more complex in recent years. Drug pricing can also be an area in which cancer care pathways could push for more cost-effective choices.

However, if there is little regulation with regard to the development of clinical pathways, the patient as well as physician community may suffer, JAMA Oncology reports. It is essential for oncologists and clinicians to drive forth the effort for creating cancer care pathways in a shared decision-making process alongside their patients.

READ MORE: ACA Risk Adjustment, Reinsurance Improved Payer Financials

“Now is also the time to bring order to the pathway world before it becomes engrained in the market and the ability to regulate it is diminished. We have been down that road before, with the rush to electronic health records— many of us are locked into systems that have not lived up to the promise of efficiency and interoperability—and none of us want to repeat those mistakes. We believe that oncology pathways, when used appropriately as proposed, can enhance patient care with less administrative burden, resulting in improved evidence-based, high-value patient care,” the JAMA Oncology article stated.

Dr. Marcus Neubauer wrote for Oncology Live that health payers are generally seeking methods for lowering costs associated with cancer care. However, when oncologists develop clinical pathways, efficacy and toxicity of the protocols are the determining components. If efficacy and toxicity are similar in two potential treatments, then cost becomes the deciding factor.

Dr. Neubauer does clarify that healthcare costs are an important part of the equation for patients and families as well. However, payers would benefit from partnering with the physician community when developing these protocols for cancer care in order to expand upon value-based payments.

For example, physicians could provide more guidelines for payers with regard to the fact that certain patients or patient populations may fall outside of the clinical pathway and require a different set of treatments. Pathway exceptions are vital to the process of cancer treatment.

Also, as payers have begun developing separate, unique clinical pathways, physicians have grown more frustrated at having to follow multiple sets of rules, according to Dr. Neubauer. Essentially, oncologists will need to have a seat at the table when developing cancer care pathways and a provider reimbursement system that “emphasizes value over volume.”

READ MORE: Independence Blue Cross, UPenn Partner to Enhance Care Delivery

“The pathways that insurance companies are pushing on physicians are nothing more than a drug formulary program and they are burdensome,” Via Oncology Medical Director Peter Ellis told the Pittsburgh Post-Gazette. “It’s really not a workable system.”

“Everybody is reading the same literature. The magic is that Via Oncology pathways are based on the literature and made by providers, who use them to provide good care.”


Sign up for our free newsletter:

Our privacy policy

no, thanks

Continue to site...