Highmark unveils new cancer reimbursement plan to save patients money
March 17, 2016 12:00 AM
State Rep. Tony DeLuca, D-Penn Hills, announces he was diagnosed with lymphoma during a news conference in Harrisburg.
State Rep. Tony DeLuca, D-Penn Hills, left, with state Rep. Eddie Day Pashinski, D-Wilkes Barre, after Mr. DeLuca announces he was diagnosed with lymphoma during a news conference in Harrisburg.
By Kris B. Mamula / Pittsburgh Post-Gazette
Highmark Health is rolling out a new way to pay for treating people with cancer, attacking the deeply entrenched practice of paying doctors for the number of procedures they perform. The new arrangement may also wind up saving money for people battling the second leading cause of death in the United States.
Under the Highmark plan unveiled Wednesday at a news conference in Harrisburg, cancer doctors will receive a bundled payment for an episode of care — on the condition they follow treatment guidelines that have been proven effective. Doctors often bristle at constraints imposed by health insurers, but the Pittsburgh insurer’s new offer gives doctors a measure of freedom that’s not otherwise possible in treating people with complex medical problems.
And doctors have been embracing the idea.
Interest in Highmark’s alternate payment method quickly outstripped the insurer’s ability to accommodate requests to participate, said Tom Pellathy, senior vice president, product network and reimbursement at Highmark. The bundled option covers radiation treatment for breast cancer, which typically lasts six to eight weeks, and 19 cancers that are treated with medication. Similar payment arrangements also are planned for other specialties, including heart care.
“For a physician, we will pay you on value and get you out of the business of driving up value for your health system,” Mr. Pellathy said.
More than 1.6 million people are diagnosed with cancer each year in the United States, with the cost of care expected to rise 48 percent to $175 billion by 2020 when compared to 2010, according to the American Society of Clinical Oncology, an Alexandria, Va.-based nonprofit.
Rep. Anthony DeLuca, 75, D-Penn Hills, was part of the news conference Wednesday, saying his own cancer diagnosis has prompted him to lead an effort to focus attention on cancer research in Pennsylvania. He’s seeking support for his resolution declaring 2016 “The Year to Cure Cancer” in Pennsylvania.
Mr. DeLuca said he was diagnosed with lymphoma about eight months ago after experiencing double vision and then a tingling feeling on a trip to Harrisburg for House session days. After months of chemotherapy, he said his doctors say he has been cured. A member of the Pennsylvania House since 1983, he is running for re-election.
Highmark’s new approach to paying for cancer treatment saves doctors from having to get pre-authorization for care while paying them a lump sum for the treatment, providing they follow treatment guidelines that have been proven effective.
The amount of the lump sum will be negotiated individually with each provider, based on the insurer’s past payments to the doctor, said Virginia Calega, vice president of medical management and policy at Highmark. “They can treat the patient as they see appropriate because the health plan is stepping out of the middle,” Dr. Calega said. “It’s not, ‘Mother, may I do this?’”
Not all cancer treatment plans are equally effective, but even good care is costly. People with cancer are about 2.5 times as likely to declare bankruptcy as those without cancer, a 2013 study at the Hutchinson Institute for Cancer Outcomes Research in Seattle found, making it critical to eliminate duplicative testing and unnecessary measures.
What’s more, the care that cancer patients receive nationwide varies widely, which has not helped people with the disease, according to a 2013 study by Arlene Forastiere, senior vice president of Philadelphia cancer information technology company eviti Inc.
An analysis of proposed cancer treatment plans for 2,544 patients by Dr. Forastiere found that one quarter did not conform to national treatment guidelines and there was no identifiable reason found for the deviation, which added an average of $25,000 to the cost of treating each patient.
Mr. Pellathy said Highmark limits participating cancer doctors to using clinically proven National Comprehensive Cancer Care Network treatment guidelines, but allows discretion in how those guidelines are used.
The region’s second largest insurer behind Highmark, UPMC Health Plan, is preparing to introduce a bundled payment plan for cancer treatment later this year, said Stephen Perkins, vice president of medical affairs, in a prepared statement. UPMC cancer doctors have been using internally developed guidelines in cancer treatment for years.
Medicare, Anthem and UnitedHealthcare are other insurers that have explored bundled payments.
The new way of paying is part of Highmark’s Cancer Collaborative, which includes a partnership with the carrier’s Allegheny Health Network and Johns Hopkins Kimmel Cancer Center.
Kris B. Mamula: firstname.lastname@example.org or 412-263-1699. Karen Langley contributed.
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