1 Magellan Rx Management, Middletown, Rhode Island.
2 Novartis, East Hanover, New Jersey.
J Manag Care Spec Pharm. 2019 Feb;25(2):235-245. doi: 10.18553/jmcp.2019.25.2.235.
Innovative health care reimbursement models are gaining attention as a way to move away from a payment system that rewards quantity of service over quality of care. One such alternative payment model is episode-based payment, such as the Oncology Care Model (OCM) being piloted by the Center for Medicare & Medicaid Innovation.
To adapt the OCM methodology to a commercially insured population to understand the challenges and potential implications of implementing an episode-based payment model in a commercial health plan.
Administrative claims databases from 3 regional commercial health plans were used to identify continually eligible patients (aged ≥ 18 years) with breast cancer, lung cancer, melanoma, or chronic myelogenous leukemia (CML). Episode triggers were identified using the OCM methodology. In calculating the episode-based payments, adjustments to the OCM methodology were necessary to adapt the methodology to a commercial population, since not all Medicare data elements used in the OCM algorithm are available in commercial claims data.
The adapted OCM-like model was applied to data from 39,967 patients with 1 of 4 cancer types. Approximately 13% of patients had at least 1 episode per year and the average number of episodes per patient per year for patients with at least 1 episode ranged from 1.42 for patients with melanoma to 1.94 for patients with CML. The percentage of total annual costs included in episodes was 49%, 60%, 34%, and 52% for breast cancer, lung cancer, melanoma, and CML, respectively.
As health care financing shifts to alternative payment models, insurers may look to adopt episode-based payments for oncology, similar to the OCM. This study shows that implementing an OCM-like model in a commercial health plan is feasible but will require adjustments to the OCM algorithm to make it implementable and applicable to populations beyond Medicare.
This study was conducted by Magellan Rx Management with funding contributed by Novartis. Zacker is an employee of Novartis. The other authors are employed by Magellan Rx Management and have nothing to disclose.
创新型医疗保健报销模式正受到关注，因为这种模式可以摆脱以服务数量而非护理质量为基础的支付体系。其中一种替代支付模式是基于事件的支付，例如医疗保险和医疗补助创新中心试点的肿瘤护理模式（Oncology Care Model，OCM）。
将 OCM 方法应用于商业保险人群，以了解在商业健康计划中实施基于事件的支付模式所面临的挑战和潜在影响。
使用来自 3 个地区性商业健康计划的行政索赔数据库，确定患有乳腺癌、肺癌、黑色素瘤或慢性粒细胞白血病（chronic myelogenous leukemia，CML）的持续符合条件的患者（年龄≥18 岁）。使用 OCM 方法确定事件触发因素。在计算基于事件的支付时，需要对 OCM 方法进行调整，以使其适用于商业人群，因为并非所有用于 OCM 算法的医疗保险数据元素都可用于商业索赔数据。
适用于 4 种癌症类型之一的 39967 名患者的 OCM 类似模型。每年约有 13%的患者有至少 1 个事件，每年至少有 1 个事件的患者的平均每个患者每年的事件数从黑色素瘤患者的 1.42 到 CML 患者的 1.94 不等。包含在事件中的年度总费用百分比分别为乳腺癌 49%、肺癌 60%、黑色素瘤 34%和 CML 52%。
随着医疗保健融资向替代支付模式转变，保险公司可能会考虑为肿瘤采用基于事件的支付方式，类似于 OCM。本研究表明，在商业健康计划中实施 OCM 类似模型是可行的，但需要对 OCM 算法进行调整，使其可实施并适用于 Medicare 以外的人群。
这项研究由 Magellan Rx Management 进行，由诺华资助。Zacker 是诺华的员工。其他作者受雇于 Magellan Rx Management，没有任何要披露的内容。
