Anthem’s Response Survivorship Medicine: Reimbursement Based on Care Coordination and Patient Outcomes

May 2016 Vol 7, No 4


Chase Doyle

Survivorship medicine has never been in more demand, but questions regarding reimbursement remain. According to Jennifer Malin, MD, PhD, Staff Vice President, Clinical Strategy, Anthem, if cancer survivorship models are to succeed, they will need to integrate into new healthcare delivery models, with less focus on cost and more on improving care coordination.

“Reimbursement for cancer survivorship needs to align with new payment models, and coordination with primary care providers and patient-centered medical homes will be key. In addition, payment models need to be sensitive to individuals’ out-of-pocket cost and their benefits,” said Dr Malin at the 2016 Cancer Survivorship Symposium.

A survey conducted from 2014 to 2015 by Anthem of 35 million Anthem-affiliated health plan members showed that the average annual cost of care for cancer survivors was $3389, Dr Malin said.

“If you pull out the costs of hospitalizations and recurrences, which are largely unavoidable, the cost for survivorship care is about $2000 per year, which, while costly, is actually not that expensive from a payer standpoint,” she reported.

Future savings, according to Dr Malin, may come from avoiding unnecessary screening tests, but practice patterns are difficult to change, because of the feelings linked to monitoring for cancer recurrence.

“The focus here should not be on cost, but on improving care coordination and the outcomes that patients care about,” she said.

Most of the revenue in oncology practice comes from treating patients with active disease. By contrast, most of survivorship care entails face-to-face time with patients, otherwise known as evaluation and management.

Evaluation and management “accounts for only 16% of the revenue of an oncology practice, but it is the bulk of the revenue for a primary care physician practice. That is where there is a bit of a disconnect,” she said. In other words, if oncologists are going to spend more time talking with patients, they want to be paid more for doing it.

A Hybrid Payment Model

New payment models, which have been accelerated by the Affordable Care Act, include population health management, accountable care organizations (ACOs), and episode-based payments, to name a few.

Anthem’s patient-centered medical home, currently dubbed “Enhanced Personal Health Care,” streamlines several of these models under one hybrid system that includes the following key components:

  • Attribution: identifying the member’s primary care physician
  • Medical cost target: establishing a budget for medical costs
  • Quality score card: establishing quality expectations that tie results to performance
  • Clinical coordination payments: changing the payment model
  • Population health management: providing data and insights about patients
  • Care delivery transformation: partnering throughout the care delivery process

“What’s interesting about this system is that it includes both patient-centered medical homes and ACOs,” said Dr Malin. “This approach really targets the continuum of primary care across multiple different settings and levels of sophistication, and it has the ability to handle population health management and patient-centered medical home–type care coordination.”

She believes patient-centered medical homes are still in their infancy.

“Anthem started its program 3.5 years ago, and it took several years just to sign people up,” Dr Malin emphasized. “We’re really now just starting to talk about the medical neighborhood, and enlarge the conversation around cancer survivorship.”

Regarding survivorship, Dr Malin and colleagues see the patient and the primary care physician at the center of an increasingly complex web of relationships.

“Specialty-focused programs are built around a strong patient-centered primary care foundation, which is helping the patient navigate this ‘medical neighborhood,’” she said.

Out-of-Pocket Costs

But out-of-pocket costs must also be considered in any reimbursement plan.

“Workers’ earnings have grown very little over the past decade, but as healthcare costs have increased, their deductibles have increased as well,” Dr Malin said. “Depending on their plans, patient exposure to out-of-pocket costs varies tremendously.”

Despite the obvious benefits, cash-strapped patients may be reluctant to add a $50 monthly payment for care coordination, she noted.

Although Anthem has looked into waiving a care-coordination fee for its members, the requirements of the Internal Revenue Service and the Employee Retirement Income Security Act of 1974 prevent this.

“These are not unmovable objects, but I think changing those regulations, so they don’t fall within people’s deductible or copay, requires advocacy, as we shift to a population health management approach,” Dr Malin concluded.

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Last modified: August 10, 2023

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