Kline Ronald M, Muldoon L Daniel, Schumacher Heidi K, Strawbridge Larisa M, York Andrew W, Mortimer Laura K, Falb Alison F, Cox Katherine J, Bazell Carol, Lukens Ellen W, Kapp Mary C, Rajkumar Rahul, Bassano Amy, Conway Patrick H
Centers for Medicare & Medicaid Services, Baltimore, MD.
J Oncol Pract. 2017 Jul;13(7):e632-e645. doi: 10.1200/JOP.2016.015834. Epub 2017 May 23.
The Centers for Medicare & Medicaid Services developed the Oncology Care Model as an episode-based payment model to encourage participating practitioners to provide higher-quality, better-coordinated care at a lower cost to the nearly three-quarter million fee-for-service Medicare beneficiaries with cancer who receive chemotherapy each year. Episode payment models can be complex. They combine into a single benchmark price all payments for services during an episode of illness, many of which may be delivered at different times by different providers in different locations. Policy and technical decisions include the definition of the episode, including its initiation, duration, and included services; the identification of beneficiaries included in the model; and beneficiary attribution to practitioners with overall responsibility for managing their care. In addition, the calculation and risk adjustment of benchmark episode prices for the bundle of services must reflect geographic cost variations and diverse patient populations, including varying disease subtypes, medical comorbidities, changes in standards of care over time, the adoption of expensive new drugs (especially in oncology), as well as diverse practice patterns. Other steps include timely monitoring and intervention as needed to avoid shifting the attribution of beneficiaries on the basis of their expected episode expenditures as well as to ensure the provision of necessary medical services and the development of a meaningful link to quality measurement and improvement through the episode-based payment methodology. The complex and diverse nature of oncology business relationships and the specific rules and requirements of Medicare payment systems for different types of providers intensify these issues. The Centers for Medicare & Medicaid Services believes that by sharing its approach to addressing these decisions and challenges, it may facilitate greater understanding of the model within the oncology community and provide insight to others considering the development of episode-based payment models in the commercial or government sectors.
医疗保险和医疗补助服务中心制定了肿瘤护理模式，作为一种基于诊疗期间的付费模式，以鼓励参与的从业者为每年接受化疗的近75万按服务收费的医疗保险癌症受益人提供更高质量、更协调的护理，同时降低成本。基于诊疗期间的付费模式可能很复杂。它们将疾病诊疗期间的所有服务支付合并为一个单一的基准价格，其中许多服务可能由不同地点的不同提供者在不同时间提供。政策和技术决策包括诊疗期间的定义，包括其开始、持续时间和包含的服务；确定模式中包含的受益人；以及将受益人分配给负责管理其护理的从业者。此外，一揽子服务的基准诊疗期间价格的计算和风险调整必须反映地理成本差异和不同的患者群体，包括不同的疾病亚型、医疗合并症、护理标准随时间的变化、昂贵新药的采用（特别是在肿瘤学领域）以及不同的执业模式。其他步骤包括根据需要进行及时监测和干预，以避免根据受益人的预期诊疗期间支出转移受益人归属，同时确保提供必要的医疗服务，并通过基于诊疗期间的付费方法建立与质量测量和改进的有意义联系。肿瘤业务关系的复杂多样性质以及医疗保险支付系统针对不同类型提供者的具体规则和要求加剧了这些问题。医疗保险和医疗补助服务中心认为，通过分享其解决这些决策和挑战的方法，可能有助于肿瘤学界对该模式有更深入的理解，并为其他考虑在商业或政府部门开发基于诊疗期间付费模式的人提供见解。
