rising costs of cancer care – financial issues from a ... · retired vp, managed care &...

RisingCostsofCancerCare–FinancialissuesfromaProvider

&ManagedCareperspectivePamelaGermain,MBA

RetiredVP,ManagedCare&Outreach;VP,StrategicInitiativesRoswellParkCancerInstitute

November11,2017s

� Deliveryofappropriate,excellentclinicalservicesandcaretopatientsonatimelybasis

� Soundfinancialpracticesimpactingproviders,payersandpatients

� Financialpolicies&proceduresthatreflectcurrentrealitiesandchallenges

Whatareourprinciplesrelatedtofinancialma3ersincancercaredelivery?

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Challengesimpac9ngProviders&Payers

� Widerangeofcostofpharmaceuticalsrelatedtoallcancers&allstagesofcare.

� Changesinpatientcareregimensinresponsetochangesinpatientstatus.

� Innovationleadingtonewtechnologies-includingtargetedtherapiesavailable&orderedbasedonmoleculardiagnostictestingresults.

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Implica9onsrelatedtothesechallenges� Methodologiesforreimbursement:

� Increasinglyvaried&complexforPharmacy� Differbypayer&sometimesbylineofbusiness–Commercial,Medicare,Medicaid

� Differbysiteofservice–inpatient,hospitaloutpatient,communitypractice

� “Bundledpricing”,Caserates,Value-BasedReimbursementforselectservices–eachofthesehasits’ownadministrativerequirements

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Wherewewere&whereweare….

�  InpreviousyearsproviderswereabletonegotiatereimbursementforoutpatientchemotherapyasapercentofAverageWholesalePrice(AWP)orasapercentofAverageSalesPrice(ASP),bydrugdefinedwitha“Jcode”plusaChemoadministrationfee…orasapercent(%)ofbilledcharges.

�  Insomeinstances,providerswere“greencarded”whichmeanttheyweren’tsubjecttopre-authorization.

� Thereweren’tasmanyindicationsforcostlytherapiesnorweretherehighcostmoleculardiagnostic(MDx)tests.

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Wherewewere&whereweare….Inrecenttimes,payerswantmuchmoreinformationinthepriorauthorizationprocess…� WhatdoNCCNguidelinesstate?�  Ispatientonaclinicalresearchstudy(CRS)?�  Ispatientonaclinicalpathway?� Whatisexpectedtimetodiseaseprogressionvs.improvedoverallsurvival?

“Greencarding”hasended&negotiationsforreimbursementincludediscussionsof:

�  “Bundledpricing”foranepisodeofcare�  Risksharing

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Abilityofproviderorganizations:� Toestablishpolicies&procedures,aswellasimplementInformationTechnology(IT),thatreflect&supporttheevolvingchangesinpayerreimbursementmethodologies.

Abilityofentire“businesssupport”team-includingthosewhoschedule,authorize&billservicestomultiplepayers:

� Toensuresystemssupportingthesefunctionscanleadtoaccuratebilling,&estimateexpectedreimbursementwheneverpossible.

Implica9onsrelatedtothesechallenges

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Implica9onsrelatedtothesechallenges

Inthiscomplexenvironmentwemust� Workasateam&communicateeffectively

� Withcolleaguesfromwithinourorganization� Withthosewithwhomwesharecaregivingresponsibilitiesforourpatients

� WithpayerswhopayforclinicalservicesWhy?

� Toserveourpatients&ensurereimbursementforappropriatecare

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Patient Care Plans involving pharmaceuticals now typically require pre- or prior authorization by a payer before there is assurance of reimbursement for molecular diagnostic testing, chemotherapy, other costly related services.

�  Often providers have a sense of urgency to start treatment before authorization is received…

�  The risk is payer denial for the care rendered!

If & when a Patient Care Plan changes, prior authorization for the new order is needed to ensure payment. If there is no updated authorization, payment is denied!

Examplesofchallengesweface

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Examplesofchallengesweface

Withtheincreasingnumberofpaymentdenialsprovidersareexperiencingduetolackofpriorauthorization-whichpayersrequirewhentheywanttoensuretheirmember/patientistoreceivecarethatmeetsthepayer’scoveragepoliciesIncreasingnumbersofproviderswillnotstarttreatmentwithoutpriorauthorization,unlessthesituationwarrantsspecialconsideration,inwhichcaseanexceptionismade…

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ExamplesofchallengeswefaceWithoutpriorauthorization,reimbursementfrommanypayersisatrisk.Adoptingthepolicyrequiringpriorauthorizationbeforetreatmentstartsensuresreimbursement…Butthisrequireseffectivecommunication&commitmenttoteamwork!

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Examplesofchallengesweface

Andwhataboutimplicationstoourpatients?Forthecareplanswearedevelopingasproviders:� Whatarethepatient’sout-of-pocketcosts?� Whattypeofinsurancecoveragedoess/hehave?� Whatprovidersarein-network?Out-of-network?� Arefinancialassistanceprogramsfromthepharmaceuticalcompanyorfromtheprovideravailable?

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Inconclusion…Therearemanyfactorsimpacting�  therisingcostsofcancercare,especiallyrelatedtotreatmentsinvolvingchemotherapyandmoleculardiagnostictesting.

�  thecomplexityofreimbursementthattypicallyincludespriorauthorization,aswellaschallengeswhencareplanschange.

Wemustworkasateaminfacingthesechallengesifwearetosustainanacceptablefinancialresult.

Thankyou!

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