Editor's note: This article, which was originally published in March 2018, was updated in August 2022.

We've seen payers and providers increasingly interested in experimenting with oncology payment models over the past few years. To assist cancer programs that are exploring alternative payments or just want to stay on top of this trend, we've provided examples and links to additional information below.

Bundled payments

• In July 2022, CMS announced the Enhancing Oncology Model (EOM) as its next medical oncology value-based payment program intended to build on the Oncology Care Model, which ended in June 2022. The model will begin in July 2023 and is voluntary for physician group practices that treat Medicare patients receiving chemotherapy. Payers can also sign on to participate. To learn more about the EOM, view our blog post on what you need to know about the model and our ready-to-present slides that provide an overview of the EOM. Use the Enhancing Oncology Model readiness assessment to review the model requirements and assess your preparedness to participate.

• In 2022, Carrum Health partnered with City of Hope to offer a non-metastatic breast cancer treatment bundle to employers at more than 35 facilities in California. Under the bundle, employers pay a single, upfront payment for patients to receive up to two years of treatment at City of Hope.

• In 2021, Carrum Health and Memorial Sloan Kettering Cancer Center (MSK) teamed up to offer comprehensive cancer care bundles for a single, upfront payment from employers. The bundle packages cover up to two years of in-person treatment at MSK for eligible patients with non-metastatic breast or thyroid cancer, as well as remote diagnosis, treatment planning, and care guidance for all forms of cancer. Read more about the partnership and bundles here.

• In June 2020, Horizon Blue Cross Blue Shield of New Jersey partnered with Astera Cancer Care and OneOncology to create episodes of care for breast, lung, prostate, colon, rectal, and head and neck cancers and multiple myeloma, with multiple episodes within some tumor sites depending on diagnosis, staging, and treatment planning. They plan to expand their episodes to additional tumor sites in the future.

• In September 2020, CMS and Center for Medicare and Medicaid Innovation (CMMI) released the long-awaited final rule for its Radiation Oncology Model (RO Model). The aim was to test whether transitioning to prospective, episode-based, site-neutral payments would reduce Medicare spending on radiation therapy while preserving or improving care quality. Under the proposed RO Model, postponed until January 2023, participants within randomly selected Core Based Statistical Areas will receive prospective payments for 90-day episodes of care for Medicare Part B beneficiaries with one of 16 different cancer types. However, in April 2022, CMS proposed to postpone the model indefinitely. To learn more about the model, read our answers to your peers’ top questions.

• In December 2019, UnitedHealthcare (UHC) launched its Cancer Episode Program (CEP), which provides episode-based payments in the place of drug reimbursement to providers of eligible chemotherapy patients. Participating providers also receive case management fees and the opportunity for shared savings. The first three practices enrolled for a full year reported a 24% decrease in total medical costs during active treatment, 39% decrease in total medical costs for patients receiving checkpoint inhibitors, 25% reduction in ED visits, and 43% reduction in inpatient admissions. The CEP was designed based on results from UHC’s cancer episode of care program phases, the first of which ran from 2009 to 2012 and included five independent oncology practices. The initial pilot resulted in total net savings of $33,361,272, representing a 34% reduction in total costs of care. Surprisingly, spending on chemotherapy increased 179%. We provided an update on the second phase of this pilot as part of our 2018 Oncology State of the Union; review the slides here.

Concluded pilots

• From July 2016-June 2022, CMMI's Oncology Care Model (OCM) its first-ever voluntary medical oncology payment program for physician practices that prescribe chemotherapy. 195 practices and 17 payers participated in this pilot in an effort to provide higher quality, more highly coordinated care. Check out our  OCM evaluation blog post or review these slides for the latest results on how OCM participants performed.

• In May 2016, Anthem Blue Cross of California and Valley Radiotherapy Associates (VRA) entered an episode-of-care payment agreement for breast cancer patients who require radiation treatment. The case rate, which lasted around 18 months, covered all services provided for treatment with the aim to create develop long-term price predictability. In 2018, VRA radiation oncologists joined City of Hope Medical Group.

• In 2015 MD Anderson and UnitedHealthcare successfully launched a bundled payment program that covered the total cost of care for 88 head and neck cancer patients over the course of two years and demonstrated the first attempt to prospectively bundle multidisciplinary cancer care. Some of the challenges with this pilot included the manual work to write claims for bundled payments and addressing new therapies as they emerge on the market. While the bundle has ended, it proved a valuable learning experience for both the provider and payer, demonstrating that bundles in oncology are possible from an administrative and logistical standpoint. We provided an update on this pilot as part of our 2018 Oncology State of the Union; review the slides here.

• In 2014, Regional Cancer Care Associates (RCCA) and Horizon BCBS piloted bundled payments for breast cancer cases being treated with chemotherapy. The program was facilitated by a proprietary data platform, COTA, which assisted with the development of individualized patient treatment plans and tracks patient outcomes.

• In 2012 21st Century Oncology and Humana negotiated bundled payments for radiation therapy for 13 frequent diagnoses, including breast, lung, and prostate cancers. A study evaluating the bundle found that providers' overall use of guideline-based care was largely unchanged; however, patients with bone metastases and prostate cancer patients experienced a significant increase in the rate of guideline-based care after the introduction of case rates. In May 2017, 21st Century Oncology filed for Chapter 11 bankruptcy protection, but it is unclear whether their bundled payment program played any role in that outcome. For more information see p.15 of Innovations in Radiation Oncology.

Shared savings programs and oncology ACOs

Ongoing pilots

• In 2021, ASCO launched the Patient-Centered Cancer Care Certification pilot, a two-year pilot culminating in the certification of outpatient oncology group practices and health systems that meet a single set of standards for patient-centered care delivery. Twelve practice groups, including 88 cancer sites and nearly 500 oncologists, participated in the pilot, with nine earning the certification in July 2022. The practices that earned certification will be assessed across 2022 as they implement improvement activities, with the pilot set to end in the summer of 2023. Anthem and Cigna agreed to share hospital utilization, drug utilization, and other data to some of the participating practices to help with the assessment of the pilot.

• In October 2021, Tennessee Oncology and BlueCross BlueShield (BCBS) of Tennessee announced an oncology medical home program in October 2021 that will award Tennessee Oncology providers financial incentives or penalties for care coordination and documentation. As part of the program, the organizations will use data analytics to track patients throughout their cancer care journey and ensure Tennessee Oncology providers follow best practice guidelines and provide patient-centered care.

• In 2020, Anthem launched an oncology medical home that was designed to align with ASCO’s Patient-Centered Oncology Payment model. Under Anthem’s oncology medical home, provider must fulfill certain core competencies and participate in Anthem’s pathways program. Providers receive a monthly care coordination fee and other financial incentives associated with improvement on quality metrics.

• In 2019, Blue Cross and Blue Shield of Minnesota entered a five year, total cost of care agreement with Minnesota Oncology. Under the agreement, Minnesota Oncology clinicians will be responsible for providing care coordination, mental health screenings, and financial counseling to Blue Cross beneficiaries and adhering to evidence-based practices. They will also be measured against a set of quality metrics. In return, they will be exempt from securing prior authorization in many cases.

• In 2019, Cigna announced the Cigna Oncology Focus Program which is intended to improve affordability and provide cancer patients a point of care that ensures all of their needs are met. It is part of the Cigna Collaborative Care program and evolved from an earlier program called Cigna Collaborative Care for Oncology. To help providers meet program goals, Cigna provides participants financial incentives, data, and operational support. In return, participating oncology practices are required to provide patients 24-7 access, provide an RN oncology care coordinator for attributed patients, utilize a shared decision- making process supported by evidence- based guidelines, and report on six quality metrics including palliative care assessment and distress screening. Cigna’s program is currently being piloted at several cancer programs and independent oncology groups and practices throughout the U.S., including Memorial Sloan Kettering Cancer Center and Florida Cancer Specialists & Research Institute in Fort Myers, FL. Because the program is new to oncology, there is little data on outcomes to be shared yet. For more information about the earlier Cigna Collaborative Care for Oncology program and oncology medical homes more generally, review this excerpt from our 2018 Oncology State of the Union.

• In 2014, Aetna launched an oncology medical home collaborative through partnership with individual cancer practices and programs. The program has now grown to include more than 20 participants, including Consultants in Medical Oncology and Hematology, Moffitt Cancer Center, RCCA, University of Michigan Rogel Cancer Center, and University of Chicago Medicine. The program measures clinical pathway adherence, reduction in ED visits and inpatient admissions, and other metrics, and includes an opportunity for shared savings.

• In 2013, Moffitt Cancer Center and Florida Blue entered into an agreement for an oncology-specific ACO. Preliminary studies show a significant reduction in inpatient readmissions, improved generic drug prescribing, and increased guideline agreement. We provided an update on this pilot as part of our 2018 Oncology State of the Union; review the slides here.

• In 2011,  Advanced Medical Specialties, a large regional payer, and Baptist Health South Florida developed the  first oncology ACO. In its first reconciliation year the ACO achieved savings of approximately 2%. Three years after its formation, Advanced Medical Specialties and Baptist Health South Florida consolidated to form the Miami Cancer Institute, which continues to report cost savings.

• In 2010, Consultants in Medical Oncology and Hematology (CMOH) contracted with two regional plans to implement care coordination and evidence-based care measures. By 2012, this had led to a 51% drop in ED visits, a 68% drop in inpatient admissions, and savings to payers of $1 million per physician per year. Today, CMOH still operates under this oncology patient-centered medical home framework.

Concluded pilots

• In 2018, Horizon Healthcare Services and RCCA created a three-year pilot program to follow patients between chemotherapy treatments. To do so, nurse navigators proactively addressed patient concerns and intervened if complications arose during the interim. The navigators were also responsible for connecting patients with transportation options and access to other facilities across the continuum of care.

• ASCO's Patient-Centered Oncology Payment (PCOP), released in 2015, encourages high-quality cancer care, while incentivizing oncologists to improve their practice. The program offers oncologists three options to transition into an alternative payment model, including  basic, consolidated, and bundled payments.  PCOP modeling suggests that practices that successfully implement the APM would reduce drug spending by 7% and emergency room utilization by 30%. The overall reduction of the cost of care could amount to 8.2% for an episode of chemotherapy. However, we are not aware of any practices actively involved in the PCOP program. ASCO released an updated version of the PCOP model in May 2020.

• In 2012, the Community Oncology Medical Home (COME HOME) pilot was funded by a three-year CMMI Innovation grant. This initiative transformed seven oncology practices around the country into oncology medical homes by implementing care pathways and elements of care coordination. CMMI reported a reduction in ED visits of about 1% and a 3.5% reduction in 30-day readmissions.

• In 2012, Priority Health partnered with Physician Resource Management and ION Solutions to launch the Michigan Oncology Medical Home Demonstration Project, which funded oncology medical home care transformation efforts among a group of participating oncology practices. The model replaced the drug margin with a per-member-per-month care management payment and saw first year savings of $550 per patient, along with reductions in inpatient admissions and emergency department visits. Priority Health transitioned this project into the Oncology Care Model in 2016.

Payer pathway programs

Ongoing pilots

• In January 2021, Cigna launched an oncology value-based pathways program. The program helps oncology providers select appropriate, safe, and cost-effective therapies by highlighting preferred regiments during the prior authorization process on the eviCore healthcare website. Providers that request one of the value-based pathways receive immediate approval.

• In January 2020, UnitedHealthcare launched its Cancer Therapy Pathways Program, which offers financial rewards to providers whose practices demonstrate at least 75% pathway adherence during six-month performance measurement periods.

• In April 2017, Blue Cross Blue Shield of North Carolina (BCBSNC) began a new Medical Oncology Program that reimburses physicians at a higher rate if they adhere to the AIM Cancer Treatment Pathways.

• In July 2014, Anthem’s Cancer Care Quality Program began. The program uses pathways developed by AIM Specialty Health to encourage physician adherence to evidence-based practices and cost-effective care, taking into account clinical effectiveness, favorable toxicity profiles, and cost to patients. Approximately two-thirds of Anthem insured patients with breast, NSCL, or colon cancer were treated on the pathway program in 2015. Physicians can receive enhanced reimbursement if they adhere to the pathways.