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CMS selects Highmark Inc. and AHN Cancer Institute for initiative promoting better cancer care

CMS Oncology Care Model attracts almost twice the expected number of physician group practices

Highmark Inc.

PITTSBURGH (June 30, 2016) — The Centers for Medicare & Medicaid Services (CMS) today announced that it has selected Highmark Inc. and the Allegheny Health Network (AHN) Cancer Institute, as one of nearly 200 physician group practices and 17 health insurance companies to participate in a care delivery model that supports and encourages higher quality and more coordinated cancer care. The Medicare arm of the Oncology Care Model includes more than 3,200 oncologists and will cover approximately 155,000 Medicare beneficiaries nationwide.

"In March 2016, Highmark Inc. and AHN Cancer Institute launched the Highmark Cancer Collaborative, a multi-disciplinary team of forward-thinking clinicians, top hospitals and medical research institutions working in collaboration to implement a replicable model of interdependent initiatives that will transform cancer patients' treatment experience by maximizing comfort, safety, outcomes and financial well-being," explained Ginny Calega, M.D., vice president of strategic clinical solutions at Highmark.

Under the Highmark Cancer Collaborative and AHN umbrella, AHN's oncologists adhere to treatment pathways developed in collaboration with the National Comprehensive Cancer Network (NCCN) and other leading cancer organizations. This brings decision support tools, which guide medical decision-making, to the point of patient care.

"AHN Cancer Institute has always been a leader in forward-thinking approaches to patient care. In the Oncology Care Model initiative, we are working with Highmark and CMS in an innovative, collaborative way to break down fragmentation and provide patients with integrated, multidisciplinary care," said David Parda, M.D., chair of the AHN Cancer Institute. "This new approach will optimize quality, access, experience and value for patients, with navigation as a critical component of our patient-centered care." Additional Highmark Cancer Collaborative initiatives include episode-of-care payment models that eliminate administrative hurdles, such as pre-authorization requirements that can be time-consuming and stressful.

The Highmark Cancer Collaborative was designed to be a replicable model for the creation and dissemination of best practices in cancer care. The model launched in western Pennsylvania on March 30, 2016, and expanded into central Pennsylvania on June 29, 2016 with PinnacleHealth partnering with Highmark on an episode-of-care payment model for outpatient treatment of breast cancer with radiation therapy. "With the simultaneous announcement that Highmark and AHN Cancer Institute will participate in the CMS Oncology Care Model, we are excited and proud to expand our model further and now contribute to the national mission to improve patient-centered care while promoting and rewarding high quality," noted Dr. Calega.

Cancer is one of the most common and devastating diseases in the United States: more than 1.6 million new cases of cancer will be diagnosed and cancer will kill an estimated 600,000 Americans in 2016. According to the National Institutes of Health, based on growth and aging of the U.S. population, medical expenditures for cancer in the year 2020 are projected to reach at least $158 billion (in 2010 dollars) — an increase of 27 percent over 2010. A significant proportion of those diagnosed are over 65 years old and Medicare beneficiaries.

"The Oncology Care Model encourages greater collaboration, information sharing and care coordination so that patients get the care they need, when they need it," said Health and Human Services secretary Sylvia M. Burwell. "This patient-centered care model fits within the Administration's dual missions for delivery system reform and the White House Cancer Moonshot Task Force — to improve patient access to and the quality of health care while spending dollars more wisely."

The Oncology Care Model encourages practices to improve care and lower costs through episode and performance-based payments that reward high-quality patient care. The Oncology Care Model is one of the first CMS physician-led specialty care models and builds on lessons learned from other innovative programs and private-sector models. As part of this model, physician practices may receive performance-based payments for episodes of care surrounding chemotherapy administration to Medicare patients with cancer, as well as a monthly care management payment for each beneficiary. The two-sided risk track of this model would be an advanced alternative payment model under the newly proposed Quality Payment Program, which would implement provisions from the Medicare Access and CHIP Reauthorization Act of 2015.

Practices participating in the five-year Oncology Care Model will provide treatment following nationally recognized clinical guidelines for beneficiaries undergoing chemotherapy, with an emphasis on person-centered care. They will provide enhanced services to beneficiaries who are in the Oncology Care Model to help them receive timely, coordinated treatment. These services may include:

  • Coordinating appointments with providers within and outside the oncology practice to ensure timely delivery of diagnostic and treatment services;
  • Providing 24/7 access to care when needed;
  • Arranging for diagnostic scans and follow up with other members of the medical team such as surgeons, radiation oncologists and other specialists that support the beneficiary through their cancer treatment;
  • Making sure that data from scans, blood test results and other tests are received in advance of patient appointments so that patients do not need to schedule additional visits; and
  • Providing access to additional patient resources such as emotional support groups, pain management services and clinical trials.

"CMS is thrilled with how many physician groups chose to be a part of the Oncology Care Model," said Patrick Conway, M.D., CMS principal deputy administrator and chief medical officer. "We have nearly doubled the number of participants that we anticipated. It's clear that oncology physicians recognize the importance of this new performance-based, episode-based payment approach to cancer care. As a practicing physician and son of a Medicare beneficiary who died from cancer, I know the importance of well-coordinated care focused on the patient's needs."

The names of those practices and payers participating in the Oncology Care Model, and more information about the model, can be found on the Centers for Medicare and Medicaid Services' website. The Oncology Care Model begins on July 1, 2016 and runs through June 30, 2021.

As part of the Administration's "better care, smarter spending, healthier people" approach to improving health delivery, the Oncology Care Model is one of many innovative payment and care delivery models developed by the CMS Innovation Center and advanced by the Affordable Care Act. The Innovation Center is committed to transforming the Medicare, Medicaid and Children's Health Insurance Program (CHIP) programs and is expected to help deliver better care for individuals, better health for populations and lower growth in expenditures for Medicare, Medicaid and CHIP beneficiaries.

About Highmark Inc.

Highmark Inc. and its health insurance subsidiaries and affiliates collectively are among the ten largest health insurers in the United States and comprise the fourth-largest Blue Cross and Blue Shield-affiliated organization. Highmark and its diversified businesses and affiliates operate health insurance plans in Pennsylvania, Delaware and West Virginia that serve 5.2 million members and hundreds of thousands of additional members through the Blue Card program. Its diversified businesses serve group customer and individual needs across the United States through dental insurance, vision care and other related businesses. Highmark is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. For more information, visit www.highmark.com.

For more information, contact:
Wendy Morphew
Highmark Inc.
412-544-3616
wendy.morphew@highmarkhealth.org