“Pathologists and medical laboratories may have to demonstrate efficiency and effectiveness to stay in the insurer’s networks and get paid for their services

In recent years, Medicare officials have regularly introduced new care models that include quality metrics for providers involved in a patient’s treatment. Now comes news that a national health insurer is launching an innovative cancer-care model that includes quality metrics for medical laboratories and anatomic pathology groups that deliver diagnostic services to patients covered by this program.

Anatomic pathologists and clinical laboratories know that cancer patients engage with many aspects of healthcare. And that, once diagnoses are made, the continuum of cancer care for these patients can be lengthy, uncomfortable, and quite costly. Thus, it will be no surprise that health insurers are looking for ways to lower their costs while also improving the experience and outcomes of care for their customers.

To help coordinate care for cancer patients while simultaneously addressing costs, Humana, Inc., (NYSE:HUM) has started a national Oncology Model-of-Care (OMOC) program for its Medicare Advantage and commercial members who are being treated for cancer, Humana announced in a press release.

What’s important for anatomic pathologists and clinical laboratories to know is that the program involves collecting performance metrics from providers and ancillary services, such as clinical laboratory, pathology, and radiology. These metrics will determine not only if doctors and ancillary service providers can participate in Humana’s networks, but also if and how much they get paid.

Anatomic pathologists and medical laboratory leaders will want to study Humana’s OMOC program carefully. It furthers Humana’s adoption of value-based care over a fee-for-service payment system.

How Humana’s OMOC Program Works

According to Modern Healthcare, “Humana will be looking at several measures to determine quality of cancer care at the practices including inpatient admissions, emergency room visits, medications ordered, and education provided to patients on their illness and treatment.”

As Humana initiates the program with the first batch of oncologists and medical practices across the US, it also will test performance criteria that anatomic pathologist groups will need to meet to participate in the insurer’s network and be paid for services.

The insurer’s metrics address access to care, clinical status assessments, and patient education. Physicians can earn rewards for enhancing their patients’ navigation through healthcare, while addressing quality and cost of care, reported Health Payer Intelligence.

“The experience for cancer care is fragmented,” Bryan Loy, MD (above), Corporate Medical Director of Humana’s Oncology, Laboratory, and Personalized Medicine Strategies Group, told Modern Healthcare. Loy is board-certified in anatomic and clinical pathology, as well as hematology. “Humana wants to improve the patient experience and health outcomes for members. We are looking to make sure the care is coordinated.” (Photo copyright: National Lung Cancer Roundtable/American Cancer Society.)

Humana claims its OMOC quality and cost measurements are effective in the areas of:

  • inpatient admissions,
  • emergency room visits,
  • medical and pharmacy drugs,
  • laboratory and pathology services, and
  • radiology.

To help cover reporting and other costs associated with participation in the OMOC program, Humana is offering physician practices analytics data and care coordinating payments, notes Modern Healthcare.

“The practices that improve their own performance over a one-year period will see the care coordination fee from Humana increase,” Julie Royalty, Humana’s Director of Oncology and Laboratory Strategies, told Modern Healthcare.

Value-Based Care Programs are Expensive

Due to the cost of collecting data and increasing staff capabilities to meet program parameters, participating in value-based care models can be costly for medical practices, according to Scottsdale, Ariz.-based Darwin Research Group (DRG), which studies emerging payer models.

Some of the inaugural medical practices in the Humana OMOC include:

  • Southern Cancer Center, Alabama;
  • US Oncology Network, Arizona;
  • Cancer Specialists of North Florida;
  • Michigan Healthcare Professionals;
  • University of Cincinnati Physicians Company; and
  • Center for Cancer and Blood Disorders, Texas.

Other Payers’ Value-Based Cancer Care Programs

“Depending upon which part of the country you’re in, alternative payment models in oncology are becoming the norm not the exception,” noted the DRG study. “Humana is a little late to the party.”

Darwin Research added that Humana may realize benefits from having observed other insurance company programs, such as:

Humana is not the only payer offering value-based cancer care programs. The Centers for Medicare and Medicaid Services (CMS) Oncology Care Model is a five-year model (2016 through 2021) involving approximately 175 practices and 10 payers throughout America (see above). The healthcare networks and insurers have made payment arrangements with their patients for chemotherapy episode-of-care services, noted a CMS fact sheet. (Graphic copyright: Centers for Medicare and Medicaid Services.)

Humana’s Other Special Pay Programs

Humana has developed other value-based bundled payment programs as well. It has episode-based models that feature open participation for doctors serving Humana Medicare Advantage members needing:

  • total hip or knee joint replacement (available nationwide since 2018); and
  • spinal fusion surgery (launched in 2019).

Humana also started a maternity episode-of-care bundled payment program last year for its commercial plan members.

In fact, more than 1,000 providers and Humana value-based relationships are in effect. They involve more than two-million Medicare Advantage members and 115,000 commercial members.

Clearly, Humana has embraced value-based care. And, to participate, anatomic pathology groups and medical laboratories will need to be efficient and effective in meeting the payer’s performance requirements, while serving their patients and referring doctors with quality diagnostic services.

—Donna Marie Pocius

Related Information:

Humana Launches Oncology Model of Care Program to Improve the Patient Experience and Health Outcomes in Cancer Care

Humana Launches Oncology Payment Model

Humana Launches Value-based Care Oncology Program for MA Members

Humana Launches New Oncology Payment Model

CMS Fact Sheet: Oncology Care Model

Humana Launches Value-based Model for Cancer Patients