NcXHF

PAGE ET AL
$350 per month per patient). The regimens were selected by
an expert physician panel based on outcomes from the medical
literature. Anthem expects the lower total cost of the selected
regimens to fund the program payments. There is no
penalty for using other regimens.
Risk sharing or gain sharing is the next progression of payment
risk. Physicians in these programs have their managed
patient’s outcomes measured and compared with another
similar population. Any savings in the managed group is
shared between the payer and the clinicians. Gain sharing is
participation only in savings, whereas, risk sharing often implies
that the physician would share in losses as well. The key
to an accurate program assessment is the quality of the comparison
group. Many risk-sharing contracts utilize a year
over the previous year comparison within the same practice.
This method often cannot adjust for the change in patient
diagnosis mix resulting in an inaccurate assessment of savings.
The ideal comparison group is treated during similar
timeframes and can be risk adjusted to match those patients
in the managed practice. The approach is no different than a
well-conducted clinical trial.
The next progression of risk is the bundled payment, which
is the ambulatory equivalent of the Diagnosis Related Group
(DRG) used for hospital reimbursement. A fıxed payment is
made to the provider for the services required to care for a
specifıc diagnosis. These payments often include multiple
disciplines and facilities. The recent MD Anderson Cancer
Center contract with UnitedHealthcare illustrates the components
of a bundled payment. Patients with head and neck
cancer are evaluated at the cancer center and assigned to one
of four risk categories. All of the services required for the
complete treatment of this patient are included under a single
payment from the payer. The bundle covers a 1-year time
period including complications. Bundles provide the incentive
to remove all of the unnecessary or nonvalue services to
maximize profıt. The MD Anderson Cancer Center used a
systematic approach to map the processes for head and neck
cancer treatment and activity-based accounting to identify
and remove unessential care. Similar to the DRG, the elimination
of complications is the other substantial way to improve
profıts under this payment system. Quality pays in
bundled payments.
Capitation is the highest form of risk. The capitated provider
assumes complete fınancial responsibility for all cancer
care in a population of patients within a fıxed budget. The
population must be well defıned with risk profıling, and actuarial
expertise is essential to manage this type of payment.
Very few organizations are capable of undertaking this type
of contracting and the authors discourage providers from attempting
this approach until they have mastered other
lower-risk programs.
IMPORTANCE OF ESTABLISHING PERFORMANCE
MEASURES
Medical practices who assume risk need infrastructure to understand
the processes they use to evaluate and treat their
patients. Mapping those processes will be both enlightening
and startling because inconsistency is usually the norm.
Adopting and driving standard approaches to common
problems eliminates waste and increases productivity—
changes that make risk contracting a profıtable approach. At
the same time, the new understanding of patient care performance
drives higher quality with fewer errors, better communication,
and rapid identifıcation of patient problems.
Those new changes are managed with internal performance
measures. No practice should assume things are
changing because they signed a risk contract; the change
must be measured and managed. These internal, quality improvement
measures can be less rigorous than external measures
and they can be adjusted frequently. The purpose of
these measures is not to obtain complete accuracy, but rather
to identify trends quickly and make adjustments. Adopting
this type of measure is diffıcult for physicians who are used to
exact measures of performance.
External measures are more rigorous and are often tied to
compensation. These measures should be limited to the vital
few because the data collection and analysis are time consuming.
Regulators often require multiple measures as an assurance
of quality in risk programs, but if too many measures
are required it can discourage participation by physicians.
Further, risk payment should not be hindered by measures
that are not required of FFS providers. The best external measures
are quite simple: survival, either disease-free or overall,
and total cost of care. Adding process measures that contribute
to these two ultimate measures distract physician resources
during the risk contract.
These principles have moved beyond the theoretical. A recent
pilot for a gain-sharing episode payment demonstrated
a 34% savings in the trial cohort compared to matched controls
in FFS payment models. 5 The MD Anderson Cancer
Center has initiated a full bundled payment for patients with
head and neck cancer. Models like these have the potential to
drive higher quality care while simultaneously saving money
by eliminating unnecessary care.
COME HOME OUTCOMES AND SUSTAINABILITY
OMHs have been shown by the COME HOME Program to
meet the triple aim: Patient care is improved, and patient outcomes
are better (lower ED visit rate, lower inpatient admission
rate, fewer inpatient days) with consistently high patient
satisfaction, all at an equal or often lower cost than local comparator
groups.
Participating oncology practices provide all outpatient
cancer care, including triage pathways that ensure patients
receive the right care in the right place at the right time for
symptoms related to cancer and cancer treatment (Fig. 2),
and clinical pathways that address appropriate imaging,
pathologic testing, and molecular diagnostics, and delineate
chemotherapy, radiation oncology, supportive care, and surgery
(when applicable). The best practices offered by OMHs
include patient education and medication management
counseling, team-based care, 24/7 practice access (telephone
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