Updating the Cancer Ecosystem: Access, Reimbursement, and Experience
The fee-for-service model of reimbursement in health care has resulted in fragmented care with no coordination across providers and care settings. This form of payment has rewarded the quantity of services offered by providers rather than the quality of the care. An alternative approach that has arisen is value-based contracting. Value-based contracting directly with the Centers for Medicare and Medicaid Services (CMS) may be impossible, which paves the way for value-based contracting through bundled payments with guidance from clinical pathways. Richard G Stefanacci, DO, MGH, MBA, AGSF, CMD, discusses how these changes provide an excellent opportunity for clinical pathways to help identify critical elements needed for value-based contracting (page 31).
In recent years, precision medicine—the integration of molecular science into the clinical care of an individual patient—has spurred efforts to develop targeted preventive strategies and disease-specific therapies. Successful implementation of precision medicine will need to address several system-wide challenges, including administrative complexities, the creation of new financing models, and aligning provider- and patient-focused initiatives. A Mark Fendrick, MD, and Margaret Shope, BS, assert that the enormous clinical potential of precision medicine sheds light on the critical importance of using clinical benefit—not acquisition price—to guide and improve how we spend health care dollars (page 39). Jason Shafrin, PhD, adds to this discussion, noting that while precision benefit design is conceptually appealing, implementing this approach in practice will require overcoming at least 3 key challenges (page 41).
As provider organizations come under increasing financial and competitive demands, there is pressure to drive expertise and health management into the community and frequently into patients’ own homes, to help reduce lengths of stay and admissions to acute care. Much discussion is needed about how providers can involve patients in their own care so that it remains safe, appropriate, and adequate. Guy Wood-Gush, MBBS, MBA, and Vivek Patkar, MBBS, MRCS, FEBS, think the creation of evidence-based pathways for use by patients would be the natural next step to help patients find the best, most evidence-based information rather than potentially unvetted information they find online (page 44). They discuss current technologies that already exist that point to this transition as well as the many issues that need to be addressed before such tools could become reality.