NcXHF

THE PATIENT-CENTERED MEDICAL HOME
cost-effective manner that produces improved outcomes,
and provide better patient satisfaction and cost savings. The
cost savings were anticipated to come from decreased utilization
of more expensive sites of care, such as the ED and
inpatient hospital facilities. A small amount of cost savings
were to come from the utilization of pathways to standardize
triage, diagnosis, and treatment of patients with cancer. This
3-year project is at maturity and preliminary data has shown
advantages to the OMH structure as carried out in the COME
HOME grant.
Alternatives to the standard FFS and buy and bill practices
in the United States have been explored. Gordon Kuntz
published fırst year results of a multipractice, community
OPCMH demonstration project in Michigan. 4 The project
reduced costs associated with unnecessary ED visits and inpatient
hospitalizations. The study suggested that community
oncology practices will embrace the transformation to a
patient-centered model with properly aligned incentives and
administrative assistance.
Newcomer et al of UnitedHealthcare compared fıve community
oncology practices with a large national payer registry
of FFS patients and proved that through a gain sharing,
episodes of care chemotherapy management coupled with
sharing of best-of-practice quality benchmarks resulted in a
34% savings in the community practices compared with
matched controls under FFS. 5 The University of Texas MD
Anderson Cancer Center has contracted with UnitedHealthcare
to manage all aspects of head and neck cancer care from
diagnosis to death under a true yearly bundled payment system.
This payment method conveys a much higher risk to the
provider, but with the potential for greater fınancial rewards
for optimal patient management. The inherent risk of this
payment model may be acceptable by large institutions but
adverse for most independent practices.
Recently, CMS has clearly announced their intent to accelerate
payment structures that move away from FFS and into
KEY POINTS
accountable, value-based bundled payments. 6 For oncology
practices to remain viable going forward, successful management
of the fınancial risks that are intrinsic to bundled payments
can be lessened by incorporating OMH processes.
These are directed at maximizing global patient management
according to appropriate accredited benchmarks.
REWARDING PERFORMANCE IN MEDICAL ONCOLOGY
A basic economic principle states that higher risk should
have the potential for higher rewards. Building an OMH requires
additional time and resources and this investment
does not make sense unless there is potential return for the
extra effort. This section discusses the new funding mechanisms
being employed to compensate for better medical oncology
performance. Potential, however, is not a guarantee of
reward. Installing the processes is not enough. The outcomes
must be better than standard performance to earn higher
rewards.
There are several options being used for performancebased
compensation (Fig. 1). The lowest risk form is pay for
performance. In this model, a bonus is paid for attaining predetermined
targets. Typically these targets are process measures
rather than outcomes. These process measures are
expected to produce better outcomes, but time and data limitations
often prevent the actual outcomes measurement.
Generally, the payments are small and the measures can be
obtained using claims data. The pay-for-performance model
has been popular for providers with large populations like
primary care practices or accountable care organizations.
The model does not work as well for medical oncology because
of the small patient numbers and the relatively small
payments for an individual practice.
Anthem uses an interesting variation of the pay-forperformance
model that pays a management fee for treating
patients with predefıned chemotherapy regimens. 7 No measurement
is required because the payment begins immediately
for each compliant patient. The payment is also larger
than most pay-for-performance programs (approximately
As we look at fee-for-service (FFS) alternatives, several
performance-based payment options exist with ranges of
financial risk, reward, and accountability.
Oncology medical homes (OMHs) have been shown to
improve patient care, patient outcomes (less emergency
department and hospital admissions), patient satisfaction,
and with substantial cost savings to the payers.
The OMH practice infrastructure required to create cost
savings is not covered under traditional FFS. Rewards for
OMH performance should be based on a small number of
meaningful quality performance measures.
To cover practice costs of an OMH, practices will need to
enter payer contracts that recognize the value of all
services provided.
An OMH infrastructure gives the best opportunity for
sustaining contracted bundled payments with risk sharing/
shared savings, which are anticipated in the near future.
FIGURE 1. Reinforcing Engagement of the Physician:
Value-Based Provider Contracting
Level of Financial Risk
Accountable Care Programs
Capitation + PBC
Shared Risk
Shared Savings
Bundled/Episode
Payments Centers of Excellence
Performance-Based
Contracts (PBC)
Primary Care
Performance-Based Programs
Incentives
Fee-for-Service
Degree of Provider Integration and Accountability
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