Doctors, insurers flock to Medicare's cancer payment demo despite questions
Skip to main content
MDHC_Logotype_white
Subscribe
  • My Account
  • Login
  • Subscribe
  • News
    • This Week's News
    • COVID-19
    • Providers
    • Insurance
    • Government
    • Finance
    • Technology
    • Safety & Quality
    • People
    • Regional News
    • Digital Edition
    • 'Little old West Virginia' sets pace on vaccine rollout
      COVID-19 hastens hospitals' revenue cycle outsourcing moves
      Operation Warp Speed Dr. Moncef Slaoui, Pfizer Group President Angela Hwang, Moderna CEO Stephane Bancel, CVS Health Executive Vice President Karen Lynch and McKesson CEO Brian Tyler participate in a panel discussion on the COVID-19 vaccine.
      Hospitals, drug companies strive to stand out virtually at JPM
      merrill goozner
      Healthcare groups should end all political donations—permanently
    • 'Little old West Virginia' sets pace on vaccine rollout
      Joe Biden
      Revamp of the nation's vaccination effort may not be enough
      COVID-19 hastens hospitals' revenue cycle outsourcing moves
      Operation Warp Speed Dr. Moncef Slaoui, Pfizer Group President Angela Hwang, Moderna CEO Stephane Bancel, CVS Health Executive Vice President Karen Lynch and McKesson CEO Brian Tyler participate in a panel discussion on the COVID-19 vaccine.
      Hospitals, drug companies strive to stand out virtually at JPM
    • The Check Up: Trenda Ray
      The Check Up: Trenda Ray of the University of Arkansas for Medical Sciences
      Trenda Ray
      Q&A: Arkansas nursing leader looking for creative staffing solutions as COVID cases surge
      Cook Lydia 4x6_i.jpg
      Northeast Ohio health systems increase community benefit values in 2019
      Vaccine rollout hits snag as health workers balk at shots
    • CMS approves rule forcing insurers to ease prior authorization
      COVID-19 still a big uncertainty for insurers in 2021
      Health insurers' outlook boosted after Dems' Georgia win
      humana_i.jpg
      Humana supports Ohio not-for-profits with $500,000
    • 'Little old West Virginia' sets pace on vaccine rollout
      Joe Biden
      Revamp of the nation's vaccination effort may not be enough
      CMS will raise Medicare Advantage plan payments by 4.08% in 2022
    • Operation Warp Speed Dr. Moncef Slaoui, Pfizer Group President Angela Hwang, Moderna CEO Stephane Bancel, CVS Health Executive Vice President Karen Lynch and McKesson CEO Brian Tyler participate in a panel discussion on the COVID-19 vaccine.
      Hospitals, drug companies strive to stand out virtually at JPM
      Intermountain, Trinity, Memorial Hermann behind $300M private equity fund
      Operation Warp Speed to bump up McKesson's stock price
      Reporter's notebook: J.P. Morgan's 2021 health conference
    • A man in a room with servers.
      Momentum grows to outsource hospital tech functions in 2021
      5 things to know about Google's $2.1B Fitbit acquisition
      Providence bets on machine-learning, consolidating data centers
      Mental health treatment was most common telehealth service during COVID
    • Sticking to Mediterranean diet is good for the brain
      Chance of COVID-19 triage care looms over Arizona hospitals
      U.S. ramps up vaccinations to get doses to more Americans
      367146427.jpg
      Should businesses mandate that staff get the COVID vaccine?
    • Cone Health CEO, CFO to depart amid pending Sentara merger
      Tower Health's finance chief resigning after years of steep losses
      AHRQ director Gopal Khanna resigns in response to Capitol riot
      Brigham president stepping down after Moderna controversy
    • Midwest
    • Northeast
    • South
    • West
  • Insights
    • ACA 10 Years After
    • Best Practices
    • InDepth Special Reports
    • Innovations
    • The Affordable Care Act after 10 years
    • New care model helps primary-care practices treat obesity
      doctor with patient
      COVID-19 treatment protocol developed in the field helps patients recover
      Rachel Wyatt
      Project to curb pressure injuries in hospitals shows promise
      Yale New Haven's COVID-19 nurse-staffing model has long-term benefits
    • Dr. James Hildreth
      How medical education can help fight racism
      Modern Healthcare InDepth: Breaking the bias that impedes better healthcare
      Videos: Healthcare industry executives describe their encounters with racism
      Michellene Davis
      Healthcare leadership lacks the racial diversity needed to reduce health disparities
      Hospital divided into multiple pieces
      Health systems may be warming to offshoring, a mainstay practice for insurers
    • A woman with a wearable sensor talking to her provider.
      Wearable sensors help diagnose heart rhythm problems in West Virginia
      self service station
      COVID-19 pushes patient expectations toward self-service
      Targeting high-risk cancer patients with genetics
      A nurse holds up a phone with a message to a family member saying surgery has started.
      Texting, tablets help hospitals keep family updated on patient care
  • Transformation
    • Patients
    • Operations
    • Care Delivery
    • Payment
    • Highmark Health inks six-year cloud, tech deal with Google
      Study: 1 in 5 patients report discrimination when getting healthcare
      HHS proposes changing HIPAA privacy rules
      Android health records app launches at 230 health systems
    • California hospitals prepare ethical protocol to prioritize lifesaving care
      Amazon, JPMorgan Chase, Berkshire Hathaway disband Haven
      Digital pathways poised to reshape healthcare continuum in 2021
      Healthcare was the hardest hit by supply shortages across all U.S. industries
    • A woman with a wearable sensor talking to her provider.
      Wearable sensors help diagnose heart rhythm problems in West Virginia
      New care model helps primary-care practices treat obesity
      How hospitals are building on COVID-19 telehealth momentum
      Researchers: Hospital price variation exacerbates health inequities
    • MedPAC votes to boost hospital payments, freeze or cut other providers
      Most Next Gen ACOs achieved bonuses in 2019
      Congress recalibrates Medicare Physician Fee Schedule after lobbying
      CMS approves rule to encourage value-based drug pricing
  • Data/Lists
    • Rankings/Lists
    • Interactive Databases
    • Data Points
    • Health Systems Financials
      Executive Compensation
      Physician Compensation
  • Op-Ed
    • Bold Moves
    • Breaking Bias
    • Commentaries
    • Letters
    • Vital Signs Blog
    • From the Editor
    • Wellstar CEO calls adapting for the pandemic her bold move
      Howard P. Kern
      Recognizing the value of telehealth in its infancy
      Dr. Stephen Markovich
      A bold move helped take him from family doctor to OhioHealth CEO
      Dr. Bruce Siegel
      Why taking a hospital not-for-profit was Dr. Bruce Siegel’s boldest move
    • Barry Ostrowsky
      Ending racism is a journey taken together; the starting point must be now
      Laura Lee Hall and Gary Puckrein
      Increased flu vaccination has never been more important for communities of color
      John Daniels Jr.
      Health equity: Making the journey from buzzword to reality
      Mark C. Clement and David Cook
      We all need to 'do something' to fight inequities and get healthcare right, for every patient, every time
    • Dr. Bruce Siegel
      By protecting the healthcare safety net, Biden can put us on the path to a stronger country
      Healing healthcare: some ideas for triage by the new Congress, administration
      Dr. Sachin H. Jain
      Medicare for All? The better route to universal coverage would be Medicare Advantage for All
      Connectivity: a social determinant of health that can exacerbate all the others
    • Letters: Eliminating bias in healthcare needs to be ‘deliberate and organic’
      Letters: Maybe dropping out of ACOs is a good thing for patients
      Letters: White House and Congress share blame for lack of national COVID strategy
      Letters: VA making strides to improve state veterans home inspections
    • Sponsored Content Provided By Optum
      How blockchain could ease frustration with the payment process
      Sponsored Content Provided By Optum
      Three steps to better data-sharing for payer and provider CIOs
      Sponsored Content Provided By Optum
      Reduce total cost of care: 6 reasons why providers and payers should tackle the challenge together
      Sponsored Content Provided By Optum
      Why CIOs went from back-office operators to mission-critical innovators
  • Awards
    • Award Programs
    • Nominate
    • Previous Award Programs
    • Other Award Programs
    • Best Places to Work in Healthcare Logo for Navigation
      Nominations Open - Best Places to Work in Healthcare
      Nominations Open - Health Care Hall of Fame
      Nominations Open - 50 Most Influential Clinical Executives
    • 100 Most Influential People
    • 50 Most Influential Clinical Executives
    • Best Places to Work in Healthcare
    • Health Care Hall of Fame
    • Healthcare Marketing Impact Awards
    • Top 25 Emerging Leaders
    • Top 25 Innovators
    • Top 25 Minority Leaders
    • Top 25 Women Leaders
    • Excellence in Nursing Awards
    • Design Awards
    • Top 25 COOs in Healthcare
    • 100 Top Hospitals
    • ACHE Awards
  • Events
    • Conferences
    • Galas
    • Webinars
    • COVID-19 Event Tracker
    • Leadership Symposium
    • Healthcare Transformation Summit
    • Women Leaders in Healthcare Conference
    • Workplace of the Future Conference
    • Strategic Marketing Conference
    • Social Determinants of Health Symposium
    • Best Places to Work Awards Gala
    • Health Care Hall of Fame Gala
    • Top 25 Minority Leaders Gala (2022)
    • Top 25 Women Leaders Gala
  • Listen
    • Podcast - Next Up
    • Podcast - Beyond the Byline
    • Sponsored Podcast - Healthcare Insider
    • Video Series - The Check Up
    • Sponsored Video Series - One on One
    • Carter Dredge
      Next Up Podcast: Ready, set, innovate! Innovation and disruption in healthcare
      Next Up Podcast: COVID-19, social determinants highlight health inequities — what next?
      Ceci Connolly
      Next Up Podcast: How to navigate the murky post-election waters
      Next Up Podcast: Saving Rural Health
    • An older man wearing a mask receiving a vaccine.
      Beyond the Byline: Verifying information on the chaotic COVID-19 vaccine rollout
      doctor burnout
      Beyond the Byline: How healthcare supply chain struggles contribute to employee burnout
      Beyond the Byline: Covering race and diversity in the healthcare industry
      Beyond the Byline: How telehealth utilization has impacted investor-owned company earnings
    • Leading intention promote diversity and inclusion
      Introducing Healthcare Insider Podcast
    • The Check Up: Trenda Ray
      The Check Up: Trenda Ray of the University of Arkansas for Medical Sciences
      The Check Up: Dr. Kenneth Davis
      The Check Up: Dr. Kenneth Davis of Mount Sinai Health System
      The Check Up: Dr. Thomas McGinn
      The Check Up: Dr. Thomas McGinn of CommonSpirit Health
      The Check Up: Mark Ganz
      The Check Up: Mark Ganz of Cambia Health Solutions
    • Video: Ivana Naeymi Rad of Intelligent Medical Objects
  • MORE +
    • Advertise
    • Media Kit
    • Newsletters
    • Jobs
    • People on the Move
    • Reprints & Licensing
MENU
Breadcrumb
  1. Home
  2. Providers
June 29, 2016 01:00 AM

Doctors, insurers flock to Medicare's cancer payment demo despite questions

Bob Herman
  • Tweet
  • Share
  • Share
  • Email
  • More
    Print

    (Story updated at 4:46 p.m. ET)

    Seventeen private health insurance companies and more than 3,200 oncologists working in almost 200 medical groups will participate in the federal government's new cancer care project, but critics argue the program may not easily lower costs or reduce unnecessary and potentially harmful care.

    The Oncology Care Model, developed by the CMS Innovation Center under authority granted in President Barack Obama's health reform law, will cover 155,000 traditional Medicare beneficiaries, officials said Wednesday. The CMS pitched the model last year with the goal of lowering Medicare expenses and improving patient outcomes through bundled payments. It starts Friday and runs for five years.

    “This is really a novel approach,” said Dr. William Conway, CEO of the Henry Ford Medical Group in Detroit, one of the program's participants. “There's a lot of fuss around the primary care model medical home. The people most in need in of better care coordination are people with cancer. This is a great opportunity to do a better job coordinating the care of patients with very complex needs.”

    The timing of the program's rollout coincides with Vice President Joe Biden's national push to cure cancer, as well as the Innovation Center's controversial attempt to change how Medicare Part B pays for outpatient drugs, like those used for cancer patients.

    Oncology groups and private payers have already experimented with different types of cancer payment models as part of the national push to move away from paying for the volume of services. But Medicare's Oncology Care Model, like other federal demonstrations, won't move completely away from the traditional fee-for-service payment structure. And health policy officials are unclear whether the episodes of cancer care are actually necessary from the outset, nor do they address the common issue of misdiagnosing cancer.

    “There's largely an assumption that if you pay for an episode, you have determined the episode is needed,” said Dr. Robert Berenson, a fellow at the Urban Institute and a former CMS director. “I don't see anything that addresses that here.”

    Berenson added the pilot project could mean the continued use of superfluous treatments and chemotherapy, but “people can get a more efficient, unnecessary episode of care.”

    Questions also remain around how the model's quality measures will influence bonus payments and physician behavior. Several studies have shown that value-based payment systems and pay-for-performance schemes sometimes fail to reach their intended goals because of overly complex designs and conflicting goals for physicians.

    Physicians enrolled in the Oncology Payment Model will be graded over six-month episodes on how they care for cancer patients who undergo chemotherapy. The episode is triggered once a patient starts chemo or doctors bill for chemo drugs, and Medicare and the private insurers will pay physicians through an elaborate performance-based methodology. Medicare Advantage members are not included.

    Participants will receive a $160 lump sum every month to provide care-management services, such as being available around the clock and coordinating appointments. In addition, performance-based payments are based on quality scores and whether providers saved money over the six-month episode of care, compared with historical fee-for-service payments.

    For the first two years of the program, physicians will be enrolled in so-called one-sided risk arrangements. That means physicians will not pay penalties for spending too much or not meeting all quality metrics. Starting in 2018, medical groups will jump into two-sided contracts, which offer higher rewards for sharing savings. However, if expenses go beyond the baseline, medical groups have to pay money back to the government.

    A major incentive for Oncology Care Model participants is the fact that the two-sided payment model counts as an “advanced alternative payment model” under Medicare's new physician payment law known as MACRA. Advanced APMs qualify for a 5% bonus payment from Medicare in 2019 and beyond.

    “That could be substantial to an oncology practice,” Jessica Turgon, principal at ECG Management Consultants, said of MACRA's bonus payments.

    But Berenson contends that making oncology groups with two-sided risk eligible for bonuses may be misguided because the program does not evaluate whether the cancer care was appropriate.

    “To give the 5% bonus just on theory isn't right,” he said.

    Oncology groups undoubtedly will encounter some bumps in the early stages, Turgon said. The care-management fee helps with investing in case managers and care coordinators, who take charge of patient care before, during and after chemotherapy. But the program's design also puts more responsibility on the shoulders of specialists instead of primary-care doctors.

    “It places more of a focus on the medical oncologist to be the coordinator of care,” said Turgon. “Do the practices have the infrastructure to do that while taking care of patients?”

    Some of the 17 insurers participating in the model are provider-owned insurers that also have their own medical groups participating. They include Banner Health and its University of Arizona Health Plans subsidiary, Henry Ford Health System, Highmark Health and Summa Health.

    Other insurers, including Aetna and several Blue Cross and Blue Shield affiliates, want to gain more experience in bundling cancer care.

    “We really believe this is the future for how our networks are going to be put together,” said Carl Lund, vice president for value-based contracting at New York-based EmblemHealth, one of the 17 insurers participating in the Oncology Care Model. EmblemHealth plans on mirroring what the CMS does in the fee-for-service program for its own Medicare Advantage population. If the payment model works, the insurer could expand the program to commercial patients, although for now the company is “starting in a very focused way,” Lund said.

    Letter
    to the
    Editor

    Send us a letter

    Have an opinion about this story? Click here to submit a Letter to the Editor, and we may publish it in print.

    Recommended for You
    The Check Up: Trenda Ray of the University of Arkansas for Medical Sciences
    The Check Up: Trenda Ray of the University of Arkansas for Medical Sciences
    Q&A: Arkansas nursing leader looking for creative staffing solutions as COVID cases surge
    Q&A: Arkansas nursing leader looking for creative staffing solutions as COVID cases surge
    Sponsored Content
    Get Free Newsletters

    Sign up for free enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox.

    Subscribe Today

    The weekly magazine, websites, research and databases provide a powerful and all-encompassing industry presence. We help you make informed business decisions and lead your organizations to success.

    Subscribe
    Connect with Us
    • LinkedIn
    • Twitter
    • Facebook
    • RSS
    • Instagram

    Stay Connected

    Join the conversation with Modern Healthcare through our social media pages

    MDHC_Logotype_white
    Contact Us

    (877) 812-1581

    Email us

     

    Resources
    • Contact Us
    • Advertise with Us
    • Ad Choices Ad Choices
    • Sitemap
    Editorial Dept
    • Submission Guidelines
    • Code of Ethics
    • Awards
    • About Us
    Legal
    • Terms and Conditions
    • Privacy Policy
    • Privacy Request
    Modern Healthcare
    Copyright © 1996-2021. Crain Communications, Inc. All Rights Reserved.
    • News
      • This Week's News
      • COVID-19
      • Providers
      • Insurance
      • Government
      • Finance
      • Technology
      • Safety & Quality
      • People
      • Regional News
        • Midwest
        • Northeast
        • South
        • West
      • Digital Edition
    • Insights
      • ACA 10 Years After
      • Best Practices
      • InDepth Special Reports
      • Innovations
    • Transformation
      • Patients
      • Operations
      • Care Delivery
      • Payment
    • Data/Lists
      • Rankings/Lists
      • Interactive Databases
      • Data Points
    • Op-Ed
      • Bold Moves
      • Breaking Bias
      • Commentaries
      • Letters
      • Vital Signs Blog
      • From the Editor
    • Awards
      • Award Programs
        • 100 Most Influential People
        • 50 Most Influential Clinical Executives
        • Best Places to Work in Healthcare
        • Health Care Hall of Fame
        • Healthcare Marketing Impact Awards
        • Top 25 Emerging Leaders
        • Top 25 Innovators
        • Top 25 Minority Leaders
        • Top 25 Women Leaders
      • Nominate
      • Previous Award Programs
        • Excellence in Nursing Awards
        • Design Awards
        • Top 25 COOs in Healthcare
      • Other Award Programs
        • 100 Top Hospitals
        • ACHE Awards
    • Events
      • Conferences
        • Leadership Symposium
        • Healthcare Transformation Summit
        • Women Leaders in Healthcare Conference
        • Workplace of the Future Conference
        • Strategic Marketing Conference
        • Social Determinants of Health Symposium
      • Galas
        • Best Places to Work Awards Gala
        • Health Care Hall of Fame Gala
        • Top 25 Minority Leaders Gala (2022)
        • Top 25 Women Leaders Gala
      • Webinars
      • COVID-19 Event Tracker
    • Listen
      • Podcast - Next Up
      • Podcast - Beyond the Byline
      • Sponsored Podcast - Healthcare Insider
      • Video Series - The Check Up
      • Sponsored Video Series - One on One
    • MORE +
      • Advertise
      • Media Kit
      • Newsletters
      • Jobs
      • People on the Move
      • Reprints & Licensing