MDs greet new Oxford program with enthusiasm
MDs greet new Oxford program with enthusiasm
One group’s perspective on episode-of-care concept
Norwalk, CT-based Oxford Health Plans received a large amount of press and industry buzz earlier this year when it unveiled its specialty care model, a method of episode-of-care reimbursement. The payer has since signed up 100 specialty teams representing 850 physicians. Physician’s Managed Care Report spoke with one provider team, New York City-based Comprehensive Breast Health of New York, about the experience the group has had with Oxford to date. The group is just beginning to see patients under the Oxford program, and hopes to add similar contracts with other payers.
Like most episode-of-care arrangements, Oxford’s specialty care model reimburses participating physician groups at a pre-set reimbursement rate for each patient the group treats within a pre-defined care episode for a specific disease. (For more on the episode-of-care concept as used in orthopedic practices, see Physician’s Managed Care Report, March 1997, pp. 25-29.) In the case of breast cancer treatment, which Comprehensive Breast Health participates in, the care episode begins as soon as a the patient is diagnosed with an abnormal mammogram or a palpable breast mass that requires a biopsy. The episode ends when the patient has completed 12 months of postoperative care.
The opinion from co-directors Saul Kaplan, MD, and Gillian Newstead, MD: Participation in the program is clearly a long-term investment, but one they believe represents the wave of the future in managed care medicine. Both say the experience of bringing a large group of specialists together to establish common clinical pathways for breast cancer, with agreed-upon costs and treatment goals, has already proven to be valuable.
In the context of a larger (combined) organization, the group can now provide services that individual organizations could not afford alone, Newstead says, such as a nurse coordinator/case manager who communicates with the patient and makes sure the care process is flowing smoothly.
Newstead’s advice to other groups interested in exploring the episode-of-care concept: Assemble a group of physicians willing to spend the time setting up a formal organization and defining the care process. She and Kaplan both stress the importance of finding an experienced consultant to help define cost parameters and to assist with contract negotiations.
Kaplan, who also serves as medical director and president of Mid-Manhattan Medical Associates, says it took one year to form the organizational structure for Comprehensive Breast Health (the group had already begun talking about the concept before Oxford announced its specialty care program), and about six months to respond to Oxford’s request for proposal. He estimates the setup costs, including renovating one floor of their present facility, equipment purchasing, and hiring new staff, to be at least $1 million. There is no hospital participation in the partnership.
Staffing is another issue the group had to address. Mid-Manhattan has a breast surgeon, oncologists, and internists. The New York University faculty practice of radiology, which Newstead is associated with, has provided the mammographers. In addition, Comprehensive Breast Health had to seek out and contract with a pathologist, a radiotherapist, and a plastic surgeon. The group also is actively seeking out a psychosocial care worker to coordinate a support program.
Even after all this fine tuning, however, the group still had to conduct a fair amount of negotiation with Oxford on rates and conditions, Kaplan says. The group was extremely concerned about identifying appropriate risk corridors to build into the contract. Issues may vary by market; Comprehensive Breast Health was primarily concerned with "opt out" provisions for patients to visit other cancer centers. "We are in proximity to other major cancer care centers, so we had to be extremely focused on that issue. We had to limit our risk corridor there."
Now that negotiations are complete, the group is focused on bringing in patients. It has kept its advertising costs minimal, and plans to host open houses for primary care physicians. Although it’s too early to tell if the program will mean financial success, the group says the specialty management program fits in well with its long-term mission.
"The main consideration is the vision of whether or not you think this is the way to practice medicine," Kaplan says; "whether you think it affords good medical practice, and enables you to do so at a lower cost."
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