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