Virtually everyone agrees that the time is now to seriously reexamine our fragmented, expensive healthcare system and to innovate sustainable approaches to curing its ills. At the center of this activity is the patient, as the ultimate consumer of healthcare services. Until recently, patients largely have been shielded from healthcare costs by health insurance and governmental payment programs with low copays/deductibles or first dollar indemnity coverage. Patients have also been relatively unaware of quality differentials because of the lack of standard reporting on meaningful quality measures.
Today, as a result of governmental and private market “transparency” initiatives, an increasing amount of quality and cost information is becoming available to the public; and patients have greater incentives to make cost effective choices about their preferred site and providers of oncology care. One of the new dynamics driving oncology consumerism is new health insurance product designs that involve higher patient copays for more expensive care options and limited, tiered and exclusive provider networks. Site of service differentials and provider-based copays are also impacting patient choices. Also driving oncology consumerism is increased activism by employer self-funded plans that are offering healthy lifestyle incentives and, in some cases, disincentives for unhealthy behaviors. Oncology consumerism is further emboldened by disruptive information and medical technologies that give patients enhanced self-care capability, with access to a trove of health information. These include electronic health monitoring and internet or home-based support services, including specialty pharmaceuticals.
While the “science” of quality and value measurement is in its infancy, some innovative oncology organizations are collecting and analyzing reams of potentially actionable data. These data analytics are an engine of evidence-based change for the benefit of consumers—but in directions that are not always intuitively obvious or welcomed by the status quo.
During this time of disruptive change, cancer care providers are understandably concerned about reimbursement reductions; about being excluded from payer contracting networks; about patient incentives to use less expensive providers; about losing referral sources as primary care physicians and other specialists align with specific networks; about the pressure to give up practice autonomy and become employees of hospitals or large multi-specialty groups; about the impact of new value-based, alternative payment arrangements (like shared savings, bundled payment, episode of care, and capitation arrangements); about the impact of ACOs, medical homes and other clinically integrated care organizations; and about the trend toward industry consolidation that threatens their professional autonomy.
In this new consumerist and cost conscious health care environment, there are critical questions to be answered about what innovative strategies and solutions are available to community oncology providers to build the successful oncology system of the future.