New Reimbursement Model Proposes a Combination of Case Management and Care Coordination in Oncology

The current American health care payment system that is tied to high-cost procedures, including cancer care, demonstrates the system’s shortfalls and inefficiencies. A shift away from the reimbursement system to one that focuses on helping providers improve outcomes for individual patients and places value on the quality of care delivered was proposed by Kavita K. Patel, MD, MS, a fellow at the Brookings Institution, and colleagues published in the November issue of the Journal of Oncology Practice.

The proposed model bundles certain services that are currently reimbursed in fee-for-service payment into two distinct payments that are not connected to those services, but tied to measurable progress-on-delivery improvement. Patel writes that the bundle would be comprised of one payment for case management that is tied to quality reporting and improvement for the oncologist. The other is a care coordination payment for the oncologist and other health care providers—including pathologists and surgical and radiation oncologists.

A case management payment does not increase the volume or intensity of patient services. The care coordination payment accomplishes a number of goals: it is paid on a per patient or per-case basis and it allows physicians the flexibility to invest in clinical practices and infrastructure without a reduction in income as a result of reductions in billable procedures that would otherwise occur. The model promotes continuous quality improvements. With the increased flexibility, physicians will decrease and eliminate waste and inefficiencies.

The current payment system encourages a buy-and-bill practice for chemotherapy drugs. Patel says this model would replace the 6% margin currently in place with a bundled payment that would be the same amount, regardless of the chemotherapy drug chosen for treatment. The 6% margin to be included in the bundle would be calculated through an analysis of all the drugs paid by Medicare to oncologists over the course of a year and recast as a case management fee paid as part of the bundle.