Creating an enhanced, common health information exchange (HIE) pipeline where clinicians, payers, and patients share structured information from multiple electronic medical record/electronic record platforms would effectively manage costs and enhance patient care in oncology, according to a recent paper published in the Journal of Oncology Practice
“Oncology needs a robust information transfer pipeline. Without information exchange and transparency, it will be difficult moving to a more value-based and outcomes-based system,” said Ira Klein, MD, MBA, senior medical director, national accounts clinical sales and strategy for Aetna.
Klein and Michael Kolodziej, MD, also from Aetna, propose to first integrate existing office electronic health records (EHRs) with the pathway/guideline support tools that are currently available (eg, eviti or P4 Healthcare Oncology). The second step involves payers facilitating Web-based pathway or guideline tools that are available and adaptable by practices and enriching those tools with other patient-specific information (eg, laboratory, pharmacy, and pathology) for low- or no-cost use by oncology practices. They note that practices would benefit by receiving real-time structured clinical data and, by interacting with a payer on the other end of the HIE, receive instant resolution of any precertification processes.
The final step involves gaining multipayer buy-in to standards of care and promoting the idea of having multiple payers have contracts with an oncology practice. This would allow for “different payers to plug into the system to create incentives and value-driven deals with oncologists, without oncologists feeling like they have to follow multiple different sets of practice requirements on one hand, and on the other, not feel like they are on the receiving end of some sort of collusive relationship with other competitive payers,” said Klein. A large, integrated system could be viewed as a buffet-style menu for community oncology practices, which allows “practices to pull out the data they need to help them develop pay-for-value programs with multiple payers.”
They argue that current pilot programs that use pathways and bundles-of-care programs are interesting, but they are not relevant to a community oncology business model. This is because only a small slice of business comes from the payers who deploy these pilot programs. Practices can’t devote a full-time employee to pilot program implementation and maintenance unless the program can be applied to the practice as a whole.
The proposed information exchange could “improve the workflow of the community oncology practice, pay practices for being smart, for keeping patients out of the hospital, and for demonstrating consistent use of evidence-based medicine,” said Klein. “If you’re in a competitive marketplace and you’re not in a single-payer system, you’re going to have barriers to sharing information. We’re proposing a methodology for allowing data to be shared, and yet continue the same market dynamics that are in existence today.”
The authors write that the unintended consequences of the Medicare Modernization Act and continuing focus on the 340B drug price program (a federal program created in 1992 that requires drug manufacturers to provide outpatient drugs to hospitals at significantly reduced prices) has dramatically shrunk community-delivered oncology care and allowed hospital-delivered care for oncology to grow. “We don’t think that’s a good idea. We don’t have any evidence that this delivers better patient care, better access, promote more personal service, or promote efficient use of services,” said Klein.
“We need to have a value-based pathway for moving community oncologists back to the forefront of care, and do it in a way without crashing the economic model,” said Klein. He recommends that oncologists join with private payers in these experiments and try to broaden and make them the standard of practice across the country. “If they do that, then community oncologists can help to shape the vision of CMS to create changes in pay for value that will be non-noxious to oncologists and non-noxious to patients.”
Klein I, Kolodziej M. Private payers and cancer care: land of opportunity. J Oncol Prac
. 2014 Jan 1;10(1):15–19.