The impact of a novel reimbursement (reimb) model on physician (phys) revenue.

Abstract

e16540 Background: CareFirst BlueCross BlueShield (CFBCBS) partnered with Cardinal Health Specialty Solutions (CHSS) to launch the first cancer care clinical pathway in the US in Aug 2008. CFBCBS, CHSS, and members of the provider network sought to create a unique mechanism of reimb for network phys as part of the pathways 2nd-generation program. Fee schedules for IV medications (meds) were reduced, and fee schedules for evaluation and management (EM) codes were increased, so that on an aggregate, weighted basis there was no expected change in overall phys reimb. This would allow phys focus on optimal treatment course without the financial incentive to prescribe chemotherapy (CT). We analyzed the impact of this novel reimb model on phys revenue after 1 year (yr). Methods: Thirty-one CFBCBS network medical oncologists comprising 14 practices volunteered to participate in the pilot program. Using the 2009 benchmark yr, all IV CT J codes, administration (admin) codes, and EM codes were analyzed. Phys were then being paid above Medicare allowable for IV meds. The design of the pilot program was to shift payment for IV meds to Medicare allowable and move the extra dollars to enhance EM codes. This process was prorated more heavily weighted towards the new pt codes. Phys were also offered the option of having meds white bagged through a specialty pharmacy. The same codes from 6 mo of 2011, the yr the plan was instituted, were collected and extrapolated to reflect 12 mo of program experience and compared to pre-program data from 2009. Results: In 2009, phys generated 25,282 J codes, 24,950 EM codes, and 19,340 admin codes. In 2011, they generated 22,288 J codes, 23,040 EM codes, and 15,634 admin codes. The net impact on phys revenue in 2011 was -1.5% (range +2% to -4%) compared to 2009. None of the practices selected the white bag specialty option. Conclusions: This data demonstrates that a reimb model that shifts the focus of reimb from drug sales to cognitive services is possible and can be created by a collaborative effort between payers and providers with minimal impact to overall phys revenue. Despite the parity that can be achieved, phys continue to prefer the “buy and bill” model. Evaluation of changes in phys patterns of care due to this reimb methodology is ongoing.