设计癌症护理商业医疗套餐：夏威夷医疗服务协会癌症病例模型。

Designing a commercial medical bundle for cancer care: Hawaii Medical Service Association's Cancer Episode Model.

机构信息

Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, 19104, USA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA; Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA.

Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, 19104, USA.

出版信息

Healthc (Amst). 2020 Jun;8(2):100422. doi: 10.1016/j.hjdsi.2020.100422. Epub 2020 Apr 6.

DOI:10.1016/j.hjdsi.2020.100422

PMID:32273240

Abstract

BACKGROUND

Oncology care is expensive and exhibits substantial variation in cost and quality across clinicians and patients. Unlike many conditions with established bundled payment programs, cancer care includes a mix of inpatient and outpatient care that precludes hospital-based designs. In 2018, we worked with Hawaii Medical Service Association (HMSA), the Blue Cross Blue Shield of Hawaii, to design a novel commercial bundle for cancer care, the Cancer Episode Model.

METHODS

Descriptive analysis of HMSA's Cancer Episode Model, including its inclusion criteria, episode definitions, suite of enhanced services, shared savings model, and incentivized quality metrics. We also compare HMSA's Cancer Episode Model to Medicare's Oncology Care Model and three major commercial oncologic alternative payment models offered by Anthem, UnitedHealthcare, and Aetna.

RESULTS

HMSA's Cancer Episode Model builds upon the successes and limitations of Medicare's Oncology Care Model and existing commercial alternative payment models. Compared to Medicare's Oncology Care Model, HMSA's Cancer Episode Model has stricter inclusion criteria, fewer incentivized quality metrics, a higher proportion of regional pricing, a different risk-adjustment model, and first-dollar shared savings. Compared to the majority of existing commercial models, HMSA's Cancer Episode Model includes total cost of care and a different risk-adjustment model.

CONCLUSIONS

Reviewing features of the Cancer Episode Model in comparison to other programs is intended to provide guidance to health plans and health policymakers in the design of programs and policies aimed at improving cancer care value.

LEVEL OF EVIDENCE

Level IV.

摘要

背景

肿瘤学治疗费用昂贵，且在临床医生和患者之间存在显著的成本和质量差异。与许多有既定打包支付计划的疾病不同，癌症治疗包括住院和门诊治疗，这使得基于医院的设计方案无法实施。2018 年，我们与夏威夷医疗服务协会（HMSA）、夏威夷蓝十字蓝盾协会合作，为癌症治疗设计了一种新颖的商业套餐，即癌症发病模型。

方法

对 HMSA 的癌症发病模型进行描述性分析，包括其纳入标准、发病定义、一整套增强服务、共享储蓄模式和激励性质量指标。我们还将 HMSA 的癌症发病模型与医疗保险的肿瘤学护理模式以及 Anthem、UnitedHealthcare 和 Aetna 提供的三种主要商业肿瘤学替代支付模式进行比较。

结果

HMSA 的癌症发病模型建立在医疗保险的肿瘤学护理模式和现有商业替代支付模式的成功和局限性基础之上。与医疗保险的肿瘤学护理模式相比，HMSA 的癌症发病模型有更严格的纳入标准、更少的激励性质量指标、更高比例的区域定价、不同的风险调整模型和首笔共享储蓄。与大多数现有的商业模型相比，HMSA 的癌症发病模型包括总治疗成本和不同的风险调整模型。