Providing Innovative Cancer Care - Expanding Episodes of Care

When someone is diagnosed with cancer, their whole life changes. Among the first things they must do is discuss treatment options with their doctor. Even after this discussion, they may face uncertainty and confusion about the many decisions they will have to make. With cancer, there is never a “one-size-fits-all” approach.

That's why it's important to provide a more holistic, personalized approach to creating a treatment plan that puts the patient at the center of care. For many physicians, this means coordinating care across multiple providers or specialists, considering other factors such as nutrition and managing what happens to a patient along the cancer care journey.

This patient-centered approach to care is the model for Horizon BCBSNJ's Episode of Care (EOC) program, which now includes a new, first-of-its-kind prospective breast cancer episode. Horizon BCBSNJ recently began the breast cancer EOC program with our value-based partner, Astera Cancer Care.

A new model for breast cancer care

Led by Drs. Bruno S. Fang and Edward J. Licitra, Astera Cancer Care will provide coordinated early-stage breast cancer treatment to patients. With a well-integrated team of established and reputable cancer providers, they can take care of patients with cancer throughout their entire episode of care treatment plan.

“We have the ability to deliver care for patients with cancer across the entire continuum of care,” said Dr. Licitra. “If someone were to be diagnosed with breast cancer, we'd have the surgeon who can do the biopsy, the surgeon who can do the surgery, the medical oncologist who can give the chemo or the endocrine therapy and the radiation oncologist who can give the radiation.”

This integrated model lets providers work collaboratively with Horizon BCBSNJ to create a community-based cancer care delivery platform and reform the way care is paid for. This enables seamless, highly-navigable care for patients with breast? cancer, who require treatments from multiple specialists, or require decisions from multiple specialists about what the best treatment is for them.

How the model works

An episode of care is a provider payment model that looks at a condition or disease from the initial diagnosis through the intermediate care and any necessary surgical and post-surgical care. An “episode” will typically include the:

• Preoperative services (such as lab work or radiology)
• Surgery itself (how the episode is triggered)
• Post-surgical care (including services like physical therapy or home care).

In the breast-cancer-specific episode, a single price is paid for an entire episode of care - whether that episode lasts six months, nine months or 12 months. Astera Cancer Care practitioners would provide the medical oncology care, the treatments, the radiation oncology care and then, if necessary, the surgical oncology care and other necessary care.

By creating a single price for the delivery of what some people would call a “bundled amount of care,” it encourages providers to deliver effective care, to properly use resources and to focus on the quality of care. Providers are also motivated to use technology and innovation to control the costs of care.

Episodes of care - transforming quality care

Episodes of care models have demonstrated the benefits of collaborating with providers across multiple care settings and holding them accountable for helping to ensure patients have the best care outcomes possible. They also help shift care from traditional fee-for-service (pay per service) to a focus on quality, value-based care, helping to drive down costs and increase positive outcomes while improving the patient experience.

With most episodes, there is generally a clear “trigger,” (i.e., the surgery), a clinical intervention or analysis that will mark ‥day 1” of the episode (e.g., some number of days prior to surgery to ensure documentation of pre-surgical care), and an end to the episode (e.g., some number of days after surgery to ensure documentation of post-surgical care). Usually, once a patient has the surgery and recovers, the episode is complete.

While oncology care may not be clearly outlined – and care is usually not set to a defined length of time – there are benefits to looking at this treatment in an episode of care model, including controlling costs and improving quality of patient outcomes.

These collaborations are transforming health care

“As a country, we're all struggling with the high cost of health care. We're looking for innovative ways to control the cost of health care. And at the end of the day, these innovative ways are going to require engagement through real partnerships,” said Dr Licitra. “Provider groups are going to have to work closely and collaboratively with payers to co-develop alternative payment models, which will result in controlling the cost of care and improving outcomes.”

As these innovative models are practiced and perfected, it gives providers an opportunity to expand into other prospectively paid episode areas including lung, prostate, rectal, and head and neck cancers, along with blood cell cancers. It will be important for providers and Horizon BCBSNJ to continue to work together to ensure health care continues to transform and evolve.