Helping Patients with Cancer Navigate Narrow Networks

Stephen M. Schleicher; Emeline M. Aviki; Thomas W. Feeley

Editorial | Journal of Clinical Oncology | September 2017

Helping Patients with Cancer Navigate Narrow Networks

by Stephen M. Schleicher, Emeline M. Aviki and Thomas W. Feeley

Abstract

The Affordable Care Act of 2010 (ACA) was designed primarily to improve patient access to affordable health care. The access-expanding provisions of the ACA included federal- and state-based health insurance exchanges with minimum coverage requirements and preexisting disease protection clauses. One effect of these access-expanding measures has been increased costs for insurers. Narrow networks, which limit patient access to certain hospitals and physician groups, represent a strategy for insurers to remain competitive in the face of increased costs. Narrow networks lower insurance premiums, in part by funneling patients toward lower-cost providers. We previously hypothesized that narrow networks might be used to adversely select against the enrollment of patients with costly chronic diseases like cancer and found that narrow networks commonly excluded stand-alone cancer hospitals, such as Memorial Sloan Kettering Cancer Center and the University of Texas MD Anderson Cancer Center. The exclusion of National Center Institute (NCI) designated cancer centers from narrow health plans is a symptom that our cancer care delivery system remains broken after the ACA. Whether we see a replacement for the ACA or a completely new health care law, the focus moving forward should be on transparency, insurance literacy, and value for patients—the best outcomes at the lowest cost.

Keywords: Health Care and Treatment; Insurance; Problems and Challenges; United States;

Format: Print

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Citation:

Schleicher, Stephen M., Emeline M. Aviki, and Thomas W. Feeley. "Helping Patients with Cancer Navigate Narrow Networks." Journal of Clinical Oncology 35, no. 27 (September 2017): 3095–3096.

Since its establishment in 2005, Hamburg’s Martini Klinik had single-mindedly focused on prostate cancer care with a commitment to measure long term health outcomes for every patient. A wholly owned subsidiary of the University Hospital Hamburg, Martini Klinik was a “hospital in a hospital” in close proximity to other medical departments and services. By 2019, Martini Klinik had become the largest prostate cancer treatment program in the world with 8,000 outpatient cases and more than 2,500 surgical cases annually. Patients came from all over Germany and from around the world. A new and expanded facility was under construction to have the capacity to manage more patients with prostate cancer.

At one point or another in our life, we all become consumers of the health care industry. Indeed, health care affects everyone and encompasses a diverse set of services from childbirth, to illness prevention, to the management of chronic disease and end-of-life care. Health care in the United States is executed through a complex set of interrelationships between three distinct parties: payers, providers, and consumers. Each group has its own perspective accompanied by a set of unique incentives, which complicate the adoption of a value-based health care system. To transform the American health care delivery system, all participants including patients, physicians, employers, insurance companies, and the government need to recognize that value is best defined as “a given health outcome per dollar of cost expended.” In this article, we examine some of the challenges to creating and implementing a value-based health care system against the backdrop of a turbulent industry and consider the implications for the anesthesiologist.

Article | NEJM Catalyst | November 8, 2018

Transitioning Payment Models: Fee-for-Service to Value-Based Care

Thomas W. Feeley and Namita Seth Mohta

In a survey of the NEJM Catalyst Insights Council in July 2018, 42% of respondents say they think value-based reimbursement models will be the primary revenue model for U.S. health care. Indeed, this transition is already happening. Respondents report that a quarter of reimbursement at their organizations is based on value, on average. While three-quarters of their revenue remains fee-for-service, we see a remarkable change to a reimbursement system that was static for decades. In particular, survey respondents’ organizations are pursuing two value-based strategies: accountable care organizations, which often use capitated payments, and bundled payments. Nearly half (46%) of respondents say value-based contracts significantly improve the quality of care, and another 42% say value-based contracts significantly lower the cost of care. The survey identifies the leading barriers to implementing value-based reimbursement models. Infrastructure requirements, including information technology (indicated by 42% of respondents), and changing regulation/policy (34%) are the top two. There is strong consensus on the broad metrics that are most important for measuring value-based care. Outcome measures top the list, with 60% of respondents saying they are extremely important. This survey suggests that many in health care see value-based reimbursement as a real solution to the nation’s current health care crisis.

Keywords: payment methods; value-based healthcare reimbursements; Health Care and Treatment; Value; Transformation;

Citation:

Feeley, Thomas W., and Namita Seth Mohta. "Transitioning Payment Models: Fee-for-Service to Value-Based Care." NEJM Catalyst (November 8, 2018). View Details

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