Collaborative, coordinated care is the catchphrase of the decade in healthcare, but for cancer patients one area of Western Pennsylvania, it has become much more.
With the launch of the new Highmark Cancer Collaborative, payers and providers are working together in a new way, removing barriers that for too long have prevented true progress in affordable and accessible cancer care.
David S. Parda, MD, FACP, professor and system chair of the department of oncology and the Cancer Institute at Allegheny Health Network (AHN), which is part of the collaborative, says he hopes the partnership will help overcome what the Institute of Medicine (IOM) calls a “cancer care crisis” in the United States.
In a September 2013 report, IOM wrote that despite remarkable advances in cancer care over the last 50 years—leading to a nearly 70% cure rate—cancer care is still inadequate and being delivered at unsustainable costs.
“We agree with this assessment and the tough solutions that are required. We need to improve patient-centered, accessible, coordinated, and evidence-based treatment and care. We need to increase the focus on prevention and psychosocial wellness as some estimates indicate that 50% of cancers may be preventable,” Parda says.
Program specifics
The collaborative is made up of a partnership between AHN, Highmark Blue Cross Blue Shield, and the Johns Hopkins Sidney Kimmel Comprehensive Cancer.
The premise is that Highmark is providing AHN physicians with a system for identifying evidence-based cancer care pathways based on patients’ individual information. Incentives for ineffective, or unproven treatments are removed and instead value-based care is pursued. Highmark is also removing pre-authorizations for cancer patients, and it is streamlining the claims and payment process to help providers get paid faster.
AHN and Highmark will focus on bringing experts together to advance cancer care on all levels—quality of care, access, experience and value for all stakeholders, says Parda.
LangbaumCancer patients can be sure that they get the most appropriate earliest treatment by getting a second opinion or confirmation of their cancer diagnosis and staging by specialists at Johns Hopkins. Johns Hopkins is also collaborating on patient cases—particularly in rare or complex cases—through direct physician peer-to-peer review and other virtual methods. It also offers joint educational programs, and participation in collaborative research projects and clinical trials.
Terry Langbaum, MHS, chief administrative office at Johns Hopkins Kimmel Cancer Center, says Johns Hopkins has had a partnership with AHN for the past two years, but the new collaboration expands the possibilities. “We are bringing together a lot of assets and all working together toward better outcomes for cancer patients,” Langbaum says.
Patients will not necessarily receive treatment at Johns Hopkins—which sees 8,000 new cancer patients each year—with the exception of rare or complex cancers, or patients who are eligible and elect to participate in a clinical trial. The majority of cancer care can and should be delivered at facilities within the patient’s community, like at AHN, she says.
“Really the whole point of it is to make sure each patient has the right diagnosis and right stage to drive the correct treatment plan, and that they are getting their treatment in the right place,” Langbaum says.
Streamlining information
AHN and Johns Hopkins are integrating their electronic health record (EHR)/IT platforms. to help providers communicate more rapidly and efficiently.
The collaborative will utilize a Web-based tool that connects to an EHR network and the physician, accessing patient information, physician, demographic, and genetic input to match it to an appropriate pathway. Physicians can even use the system for patients not in the Highmark system.
The system will also allow physicians access to cost information, so that they can discuss it with concerned patients. “Those kind of discussions are critically important, and patients want to have those discussions with their clinical team. What are the options, and what are the side effects, and what is going to be their quality of life?” says Virginia Calega, MD, MBA, FACP, vice president of strategic clinical solutions at Highmark Blue Cross Blue Shield. “If you can make the payment more predictable both for the doctor and the patient, it takes that worry away from them.”
Calega says the collaboration brings providers and payers together in a new way to really focus on improving access, affordability, and appropriateness of care.
For example, she points to the use of therapeutic radiation. For years, providers have used six-week courses of radiation to treat breast cancer, but now research shows that a three-week course can be just as effective with less negative effects, says Calega. “Outcomes are equivalent with less toxicity,” she says, adding the shorter course is just as effective as the longer one but is easier for the patient and more affordable.
Under the collaborative, providers get paid the same for a six-week course of treatment or a three-week course. Prior authorizations are removed, and providers get half of the payment up front and half at the end of treatment.
Criticisms and concerns
While care pathways have received some criticisms for impinging on physicians’ autonomy, Calega says that is not the case in this collaboration. “It’s not just about pathways, but it models and incentives to get people the care they need,” she says. “You don’t use pathways as a prior authorization, you use them to help people get better.”
Physicians are usually pleasantly surprised once they understand how the collaboration works; that they no longer need to deal with prior authorizations, and that they will be rewarded for caring for patients in accordance with National Comprehensive Cancer Network pathways, she says.
Highmark also plans to sit down with physicians and look at historic data to come up with a payment rate for patients in various cancer groups. “We’re going to pull prior authorization and we’re going to sit down with [physicians] and say, ‘How are we doing?’” Calega says. “We’re really able to not just look at pathways but how we reimburse differently for pathways. That’s the piece where I think having a partnership with an insurance [company] changes the conversation in the marketplace.”
The formation of the collaboration was not without challenges, though.
“A collaborative model of this scope across provider and payer environments has never been done to my knowledge so that was a challenge. And it was a new type of collaboration for Hopkins which required a lot of due diligence for an iconic medical institution like Hopkins to work with a new health system (AHN) and a new integrated delivery and finance system (Highmark Health),” Parda says. “We were able to consummate an innovative collaboration like this due to the forward-thinking expertise, and trusted collaborative/patient-centered values of both institutions.”
Administrative burdens are a common hurdle in healthcare processes for both caregivers patients. Parda says AHN, Highmark, and Johns Hopkins are all working together to try and make the process more seamless.
“We are trying to optimize our processes and connections on both provider and payer sides to facilitate efficient collaborative work between both institutions and many people. We are explicitly working on eliminating as many administrative burdens as possible to improve value and experience for both cancer patients and the healthcare professionals who care for them,” Parda says. “This is helping to ease the administrative burden of seeking second opinions for both patients and physicians and making many other collaborations easier to do. We are also working together on reimbursement methods like episode of care and bundled payments to limit administrative burdens for patients, providers, and payers.”
The easing of administrative burdens not only reduces stress for the patient and the physician, but also for support staff through less initial administrative hoops, but also less work in re-filing paperwork or handling any claim rejections. Highmark will also be tracking how fast physicians are paid, and breaking down the payment cycle to identify and resolve any obstacles.
“Cash flow is critical right now to the provider, and it’s helpful to get it as fast as possible,” Calega says. “For us, it’s about being at the forefront of changing how we deliver and pay for cancer treatment. How do we move people more onto to value-based reimbursement where we’re focused on the outcomes of the patient and removing those emergency room visits?”
The collaborative is also looking at more ways to improve care under the cancer care umbrella, including opening after-hours cancer care centers to try and keep patients out of emergency rooms, and home-care to help patients move out of the inpatient setting sooner.
“This model is different than others as we are working together to accelerate advances in patient care, education, research, clinical trials, genomics, and care transformation across provider and payer environments in a way to provide better care for cancer patients within integrated community and quaternary care delivery settings,” Parda says. “What makes it work is the leading expertise of the collaborators and the intense focus on improving care, outcomes, and value for cancer patients.”
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