Purpose: With the advent of newer cancer therapies (eg, biologic and cytotoxic), treatment is becoming increasingly expensive for patients with cancer. Patients enrolled in Medicare and commercial insurance plans often have large copay requirements with each treatment cycle. Often, these patients undergo significant financial hardship, and some patients decline treatment. We have developed a support program that works closely with all copay assistance foundations to secure financial assistance to facilitate appropriate treatment.
The Wilshire Oncology Medical Group has worked in many payment systems during its 54-year history. Our experiences have led us to develop a medical oncology home pilot to offer a transparent, high-quality, high-value cancer program in partnership with our largest California health plan, Anthem Blue Cross WellPoint. Changes in how we were paid by independent physician associations were the catalyst of a 20-year process of re-engineering our care delivery while maintaining participation in clinical trials. We became pioneers in staffing models and the use of an oncology electronic medical record (EMR) system. The EMR prompted us to be diligent in the evaluation and monitoring of both practice and clinical data and allowed us to use data at the practice level to create ongoing programs for continuous quality improvement. 1,2 By 2006, we had transitioned to a customizable oncology-specific EMR standardized to incorporate treatment protocols on the basis of evidencebased medicine. We began analyzing our data to benchmark the care we provided against national guidelines. 3-5 Today as a member of the nation's largest network of community-based oncologists, we continue to document our adherence to Level 1 Pathways and the costs and quality of care we provide 6-10 and to study complex quality issues in cancer. 11 We next planned how we could better serve the preferred provider organization health plans in our market. Our goal was to demonstrate that we could deliver a comprehensive plan of care and manage their patients with cancer while creating significant savings to the patients who were facing growing copay burdens 12,13 and the health plans that could save in lowered direct and management costs for therapy and supportive care, lessening avoidable urgent, emergency, hospital care and futile, toxic therapies at the end of life. The practice would benefit from these cost savings through value-based reimbursement and lessened management by the health plan.Four years ago, we contacted the senior leadership of the largest preferred provider organization in our market. We wanted to explore how we might share our work with the health plan and develop what we initially called a 'pay differently for better outcomes' plan. Despite the fact that our comprehensive approach did not fit into their previous oncology management models, the medical directors of this payer believed our proposal had merit and initiated what became a series of ongoing meetings between our groups. This led to an agreement to validate our clinical and claims data, which brought the health plan analysts and actuaries into the discussions. These talented, professional actuaries were able to build models to analyze regimens by patient and regional groups, supportive care drugs, and days of emergency room care differentiated by weekday versus weekend and evaluate global hospital claims data. They validated the patient data we could rapidly pull on a real-time basis from our EMR and billing reports; whereas this proved to be a complex, time-consuming undertaki...
6630 Background: With advent of newer CT (biotherapy, chemotherapy, and supportive care) treatment is becoming increasingly expensive for cancer pts. Pts enrolled with Medicare and commercial insurance plans often have large copay requirements with each treatment cycle. Often, these pts undergo significant financial hardship and some pts decline treatment. We have developed a novel support program to coordinate all copay assistance foundations (FDNs) in order to secure financial assistance to facilitate appropriate CT. Methods: In September, 2008 in our multi-site cancer center (11 oncologists, 6 CT sites), we developed a dedicated support program to coordinate pt applications to copay assistance FDNs including Healthwell, Cancer Care, Patient Access, Chronic Disease Fund, Beckstarnd Cancer, Lilly Cares, and Leukemia and Lymphoma Society. Pts requesting assistance with CT copay were enrolled in this program. A dedicated staff individual obtained information about diagnosis, insurance, income level, CT plan and associated co-pay requirements. Data was given to FDNs who determined the amount of monetary assistance. Responses of FNDs and administrative costs were analyzed. Results: Of 264 pts started initiating CT between September 2008 and December 2008, 25 (9.3%) requested assistance for either IV or PO treatments. The average interval between the submission of FDN application and date of determination of assistance was 10 days. Out of 83 applications (3.32 applications/pt), 50 (60%) were approved. Ultimately 22/25 pts received FDN support of $113,475. The most common reasons for denial were if the pt's income exceeded a certain level, exclusion of coverage of certain medications and the FDN being out of funds. The administrative costs associated with this program were $18,000/yr ($720/pt, or $217/application). Administrative costs were 1.64% of approved support. More difficulties were encountered with applications for oral CT than IV CT. Conclusions: Copay for CT drugs is a financial hardship for a significant number of pts. Coordinated resources must be provided and reimbursed to facilitate appropriate and sustainable cancer care. This program is a successful model for other centers. No significant financial relationships to disclose.
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