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ARTICLE Cancer Care Reimbursement Model

UnitedHealthcare is conducting a pilot study with leading oncology groups to fight the most common cancers in creative, practical ways. There are two aspects of the study:

  • First, the new approach reimburses oncologists upfront for an entire cancer treatment program, instead of the current "fee-for-service" approach, which rewards volumes of care regardless of health outcomes.
  • Second, over the course of the pilot, various treatment regimens will be evaluated to identify which are the most effective for a range of clinical presentations.

Smarter reimbursement

Under the current system, oncologists recommend a specific treatment program that commonly includes chemotherapy drugs and administers them to the patient in his or her office. The oncologist then bills the patient's health nsurance plan or payer for the retail price of the drugs, plus a charge for administering the drugs.

This new reimbursement model pays a new patient care fee for a patient's total cycle of treatment – it represents the profit margins oncologists made from the drugs. It will remain the same no matter what chemotherapy drugs are given, but the drug cost is always reimbursed. The new program, in effect, separates the oncologist's income from drug sales while preserving his or her ability to maintain a regular visit schedule with the patient.

Clinical best practices

Each medical group will choose a standard chemotherapy regimen for one of 19 clinical presentations and participate in performance reviews of their data to identify best practices. Treatment regimens will be evaluated based on the number of emergency room visits, incidence of complications, side effects and, most importantly, health outcomes – that is, which treatments do the best job of fighting cancer.

As oncologists share best practices about which treatments are most effective – with no loss of revenue for the physician – we hope to see consistently improved patient outcomes.