Becker's Hospital Review

12 Sign up for the COMPLIMENTARY Becker's Hospital Review CEO Report & CFO Report E-Weeklies at www.BeckersHospitalReview.com or call (800) 417-2035 later, UnitedHealthCare may offer performance-based reimbursement for compliance with its protocol. "Soon you have five different protocols to use with different patients," said Mr. Belokrinitsky. "You might end up with competing or conflicting protocols, and that will drive physicians crazy. Whoever can bring harmony to the process would be the physician's best friend" Another challenge is hospitals' and oncologists' opposition to attempted standardization. A lot of time and research goes into clinical protocols. Payors typically develop clinical protocols with outside experts who continue to update the protocols regularly as new studies, technologies and treatment options become available. But if a payor calls one of the country's most prominent cancer centers asks those oncologists to use its clinical protocol — those physicians may not be too pleased, said Mr. Belokrinitsky. Cancer hubs with the top talent, research and cutting-edge technology may be more likely to resist payors' clinical protocols or care management tools. Improved prescription management. A 2011 study published by the Journal of Oncology Practice and the American Journal of Managed Care found 10 percent of patients failed to fill new prescriptions for oral cancer drugs. Researchers found people with high cost-sharing in their insurance plans and those who were on multiple medications were more likely to abandon their prescriptions. Roughly 16 percent of patients had an out-of-pocket cost of greater than $500, according to the study. One way to alleviate this problem is through split-fill prescriptions, where patients can pick up a portion of the pills — maybe 10 of their monthly 30 — for a fraction of the cost. This way, if the medication causes discomfort or negative side effects, the payor will not reimburse the full cost of a medication that goes unused, the physician will be notified of those side effects and can change the patient's prescription, and the patient will not have to purchase an expensive oral drug with high out-of-pocket costs that is ineffective. End-of-life planning. There are also care management costs that are based largely on common sense and practicality, such as patients, physicians and family members having end-of-life discussions early on. "Once clinical measures have been exhausted, you can shift to less-invasive treatments that will make patients more comfortable and provide [them with] some dignity as they live out the rest of their lives. The earlier the physician has that conversation with a patient and their family, the less likely they are to choose invasive options," says Mr. Belokrinitsky. "If you don't gently but candidly discuss end-of-life planning, patients will likely ask for more care. More health plans will look to deploy these programs to transition patients to less-invasive care when they are ready." San Antonio's Children's Hospital Boom: How Alamo City Competitors Are Battling for Pediatric Patients (continued from page 1) a freestanding hospital is a necessary credential to attract scarce pediatric subspecialists for the area's multiplying patients. Out with the old The eight-county San Antonio metropolitan area has averaged an annual population growth rate of 2.5 percent, or about 43,000 residents each year since 2000. And the area had the largest numeric growth in population of any of the nation's largest 10 cities between 2010 and 2011, according to the U.S. Census Bureau. As of last July, the area's population sits at around 2.23 million. Noticing the city's patient base was growing, hospitals in the area began to explore expansion opportunities, including in pediatrics. Genetic testing. One care management tool that holds promise is personalized medicine, or genetic testing, which is applicable for subsets of cancer. These tests can be useful when certain types of cancer seem to run in patients' families, but they are not recommended for everyone. The blood tests can identify gene mutations and potentially determine what type of cancer a patient is most at risk of developing, and whether the patient will be responsive to a certain type of medicine. One caveat: There are no laws requiring insurance companies to cover genetic testing, and bills can range in cost, from $100 in out-of-pocket costs or running in the thousands. Actress Angelina Jolie brought wider public understanding to genetic testing in May when she wrote a New York Times op-ed about her choice to undergo a double mastectomy after testing positive for a high-risk gene mutation, BRCA1. Physicians estimated she had an 87 percent risk of breast cancer and 50 percent risk of ovarian cancer, although those figures are prone to fluctuation in each woman's case. Ms. Jolie said the price for BRCA1 and BRCA2 testing can exceed $3,000 in the United States — a financial obstacle for many. Shortly after Ms. Jolie's op-ed, Peter Meldrum, president and CEO of Salt Lake City-based Myriad Genetics & Laboratories, wrote a letter to the newspaper. He noted that the company's BRACAnalaysis is widely reimbursed by insurance companies, with more than 95 percent of at-risk women covered and with an average out-of-pocket cost of about $100. "And, thanks to preventive care provisions in the Affordable Care Act, many patients can receive BRACAnalysis testing with no out-of-pocket costs," Mr. Meldrum wrote. Conclusion Cancer is already a huge part of population health management, and is projected to be even more prominent in the next few years. Today, more than 60 percent of cancer diagnoses affect Medicare beneficiaries, and that number is projected to reach 70 percent by 2030. This growing need for cancer care; hospitals' growing investments in their oncology programs, technology and centers; and increased national attention on the financial costs of cancer all suggest ample opportunity for reform in oncology reimbursement. It seems this challenge can be addressed in ways that are mutually beneficial for providers and payors, allowing the two to genuinely meet one another halfway. Closer collaborations between healthcare providers and new programs like cancer-specific ACOs, bundled payments and clinical protocols have given both sides of the equation sharper tools to reduce variation in cancer care while improving outcomes. n In December 2010, San Antonio-based Christus Santa Rosa Health System and University Health System, the Bexar County-owned hospital affiliate staffed by faculty physicians of the School of Medicine at The University of Texas Health Science Center in San Antonio, initiated discussions to partner with one another to build a new standalone children's hospital, which would have been the city's first. Christus and University Health leaders hired a consulting group to help analyze a potential agreement, but the idea was abandoned in early 2012, says Francisco González-Scarano, MD, dean of medicine and vice president of medical affairs at the Health Science Center. A major reason the plan was aborted was because the two systems couldn't agree on where to locate the children's hospital, Dr. Gonzalez says. Christus pushed to build it downtown near its existing adult hospital, Christus Santa Rosa Hospital, which housed its co-located Christus Santa Rosa Children's Hospital. University Health, on the other hand, wanted the new standalone children's hospital to complement the Health Science Center's medical school on its academic campus about 10 miles away. Twenty years before, Christus, Methodist and the Health Science Center had all explored partnerships with one another to build a standalone children's hospital, but ultimately abandoned those attempts over similar disagreements regarding location. That setback led Christus to add pediatric facilities to its downtown hospital some years later. This time, Christus responded to the location dispute stalemate by boldly announcing it would decommission and gut its adult hospital downtown to renovate and convert it into a standalone children's hospital, known today as Children's Hospital of San Antonio.

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