Partnering With a Payer to Develop a Value-Based Medical Home Pilot: A West Coast Practice's Experience

Abstract

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...

Alternative payment and care‐delivery models in oncology: A systematic review

“…Characteristics and results from the included studies are presented in Table . The 23 articles that met inclusion criteria described 22 unique interventions, including 6 (27%) bundled payments, 4 (18%) ACOs, 9 (41%) PCMHs, and 3 (14%) other alternative payment or care‐delivery models . The majority of interventions that reported practice setting were implemented in the community (n = 16 of 21; 76%), and most that reported payer type involved private payers (n = 13 of 15; 87%).…”

“…Five of the 7 oncology PCMHs took place in community settings, and 1 occurred in mixed settings; 1 PCMH did not report setting information. Four of the oncology PCMHs contracted with private payers, 1 contracted with Medicare, 1 contracted with mixed payers, and 1 did not report payer type …”

Value and payment for oncology in the United States

“…A different but compatible payment initiative was developed by WellPoint in collaboration with a major oncology practice [10]. The concept of the medical home had emerged in primary care as a means to expand the scope of care from patient visits to a more comprehensive set of activities involving non-physician staff, the patient, and the patient's family.…”

From the First Visit On: Information Technology and Communication

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