Development and Feasibility of Bundled Payments for the Multidisciplinary Treatment of Head and Neck Cancer: A Pilot Program.

PURPOSE: Despite growing interest in bundled payments to reduce the costs of care, this payment method remains largely untested in cancer. This 3-year pilot tested the feasibility of a 1-year bundled payment for the multidisciplinary treatment of head and neck cancers. METHODS: Four prospective treatment-based bundles were developed for patients with selected head and neck cancers. These risk-adjusted bundles covered 1 year of care that began with primary cancer treatment. Manual processes were developed for patient identification, enrollment, billing, and payment. Patients were prospectively identified and enrolled, and bundled payments were made at treatment start. Operational metrics tracked incremental effort for pilot processes and average payment cycle time compared with fee-for-service (FFS) payments. RESULTS: This pilot confirmed the feasibility of a 1-year prospective bundled payment for head and neck cancers. Between November 2014 and October 2016, 88 patients were enrolled successfully with prospective bundled payments. Through September 2017, 94% of patients completed the pilot with 6% still enrolled. Manual pilot processes required more effort than anticipated; claims processing was the most time-consuming activity. The production of a bundle bill took an additional 15 minutes versus FFS billing. The average payment cycle time was 37 days (range, 15 to 141 days) compared with a 15-day average under FFS. CONCLUSION: Prospective bundled payments were successfully implemented in this pilot. Additional pilots should study this payment method in higher-volume cancers. Robust systems are needed to automate patient identification, enrollment, billing, and payment along with policies that reduce administrative burden and allow for the introduction of novel cancer therapies.

Second-opinion pathologic review is a patient safety mechanism that helps reduce error and decrease waste.

PURPOSE: We have a crisis in health care delivery, originating from increasing health care costs and inconsistent quality-of-care measures. During the past several years, value-based health care delivery has gained increasing attention as an approach to control costs and improve quality. One proven way to control costs and improve the quality of health care is subspecialty pathologic review of patients with cancer before initiation of therapy. Our study examined the diagnostic error rate among patients with cancer treated at a tertiary care hospital and demonstrated the value of subspecialty pathologic review before initiation of treatment. METHODS: From September 1 to September 30, 2011, all patients seeking a clinical consultation had pathology submitted to and reviewed by a pathologist with subspecialty expertise and correlated in our pathology database. RESULTS: A total of 2,718 patient cases were reviewed during September 2011. There was agreement between the original pathologist and our departmental subspecialty pathologist in 75% of cases. In 25% of cases, there was a discrepancy between the original pathology report and the subspecialty final pathology report; 509 changes in diagnosis were minor discrepancies (18.7%), and in 6.2% of patients (169 reports), the change in diagnosis represented a major discrepancy that potentially affected patient care. CONCLUSION: Second review of a patient's outside pathology by a subspecialist pathologist demonstrates the value of multidisciplinary cancer care in a high-volume comprehensive cancer center. The second review improves clinical outcomes by providing patients with evidence-based treatment plans for their precise pathologic diagnoses.

Ensuring quality cancer care: a follow-up review of the Institute of Medicine's 10 recommendations for improving the quality of cancer care in America.

Responding to growing concerns regarding the safety, quality, and efficacy of cancer care in the United States, the Institute of Medicine (IOM) of the National Academy of Sciences commissioned a comprehensive review of cancer care delivery in the US health care system in the late 1990s. The National Cancer Policy Board (NCPB), a 20-member board with broad representation, performed this review. In its review, the NCPB focused on the state of cancer care delivery at that time, its shortcomings, and ways to measure and improve the quality of cancer care. The NCPB described an ideal cancer care system in which patients would have equitable access to coordinated, guideline-based care and novel therapies throughout the course of their disease. In 1999, the IOM published the results of this review in its influential report, Ensuring Quality Cancer Care. The report outlined 10 recommendations, which, when implemented, would: 1) improve the quality of cancer care, 2) increase the current understanding of quality cancer care, and 3) reduce or eliminate access barriers to quality cancer care. Despite the fervor generated by this report, there are lingering doubts regarding the safety and quality of cancer care in the United States today. Increased awareness of medical errors and barriers to quality care, coupled with escalating health care costs, has prompted national efforts to reform the health care system. These efforts by health care providers and policymakers should bridge the gap between the ideal state described in Ensuring Quality Cancer Care and the current state of cancer care in the United States.