July 21, 2015
Co-presenters answer participants’ questions on alternative payment models for oncology care that were not answered during the webinar.
Jennifer Malin, MD, PhD - Anthem
We don’t have an episode. We do a case management fee. Our care coordination fee is on a monthly basis. There is no defined episode.
Therapy targeted on specific biomarkers goes back 30 years, such as the use of Tamoxifen for hormone receptor-positive breast cancer. So this isn’t new, it is just accelerating. There is no current evidence for doing large gene panels to see if a tumor has one of 100 different variations. But for specific cancers, there are specific mutations that can lead to better treatment. They are included in our pathways.
It is too early to see.
Unfortunately, for payment of claims, data must flow into our IT system. However, we have combined the prior authorization process with the claims process. By combining these two processes into one step we have decreased the administrative burden.
Lee Newcomer, MD, MHA - UnitedHealthcare
This is proprietary information.
We allow the physicians to make the choice. In all situations we’ve seen, the regimens are very comparable for results. We haven’t seen a physician choose an inferior regimen. Physicians are allowed to make a change anytime based on patient preference.
Timeframe is assigned based on the regimen for adjuvant treatment. Metastatic episodes are defined as four-month periods with renewals.
There are specific cancers with specific genomic tests that are helpful. For example, HER2 for breast cancer and ALK for lung cancer. Like any new evidence, they should be incorporated into the protocols if and only if the evidence shows unequivocal responses.
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Emily DuHamel Brower, M.B.A., is senior vice president of clinical integration and physician services for Trinity Health. Emphasizing clinical integration and payment model transformation, Ms. Brower provides strategic direction related to the evolving accountable healthcare environment with strong results. Her team is currently accountable for $10.4B of medical expense for 1.6M lives in Medicare Accountable Care Organizations (ACOs), Medicare Advantage, and Medicaid and Commercial Alternative Payment Models.
Mr. James Sinkoff is the Deputy Executive Officer and Chief Financial Officer for Sun River Health (formerly known as Hudson River HealthCare), and the Chief Executive Officer of Solutions 4 Community Health (S4CH); an MSO serving FQHCs and private physician practices.
Victor is the Chief Medical Officer for TennCare, Tennessee’s Medicaid Agency. At TennCare, Victor leads the medical office to ensure quality and effective delivery of medical, pharmacy, and dental services to its members. He also leads TennCare’s opioid epidemic strategy, social determinants of health, and practice transformation initiatives across the agency. Prior to joining TennCare, Victor worked at Evolent Health supporting value-based population health care delivery. In 2013, Victor served as a White House Fellow to the Secretary of Health and Human Services. Victor completed his Internal Medicine Residency at Emory University still practices clinically as an internist in the Veteran’s Affairs Health System.
Dr. Brandon G. Wilson, DrPH, MHA (he, him, his) joined Community Catalyst as the Director of the Center for Consumer Engagement in Health Innovation, where he leads the Center in bringing the community’s experience to the forefront of health systems transformation and health reform efforts, in order to deliver better care, better value and better health for every community, particularly vulnerable and historically underserved populations. The Center works directly with community advocates around the country to increase the skills and power they have to establish an effective voice at all levels of the health care system. The Center collaborates with innovative health plans, hospitals and providers to incorporate communities and their lived experience into the design of systems of care. The Center also works with state and federal policymakers to spur change that makes the health system more responsive to communities. And it provides consulting services to health plans, provider groups and other health care organizations to help them create meaningful structures for engagement with their communities.
Tamara Ward is the SVP of Insurance Business Operations at Oscar Health, where she leads the National Network Contracting Strategy and Market Expansion & Readiness. Prior to Oscar she served as VP of Managed Care & Network Operations at TriHealth in Southwest Ohio. With over 15 years of progressive health care experience, she has been instrumental driving collaborative payer provider strategies, improving insurance operations, and building high value networks through her various roles with UHC and other large provider health systems. Her breadth and depth of experience and interest-based approach has allowed her to have success solving some of the most complex issues our industry faces today. Tam is passionate about driving change for marginalized communities, developing Oscar’s Culturally Competent Care Program- reducing healthcare disparities and improving access for the underserved population. Tamara holds a B.A. from the University of Cincinnati’s and M.B.A from Miami University.
Dr. Peter Walsh joined the Colorado Department of Health Care Policy and Financing as the Chief Medical Officer on December 1, 2020. Prior to joining HCPF, Dr. Walsh served as a Hospital Field Representative/Surveyor at the Joint Commission, headquartered in Oakbrook Terrace, Illinois.
