Despite multiple studies demonstrating the case management derived savings, the lack of standard guidelines and validated evaluation tools hamper consistent identification for cancer patients. ⁴ A systematic review of multiple studies reported incremental cost-effectiveness ratios below a willingness-to-pay threshold of US $50,000 for the gain of 1 quality-adjusted life year (QALY).⁵ Significant benefit and savings are derived from the management of high-intensity intervention such as self-management, clinic visits, hospital admission, length of stay, emergency department visits, and inpatient cost.⁶

Currently, billing for cancer case management activities uses the CMS procedural terminology codes for care management for chronic conditions.⁷

The American Cancer Society defines patient navigators as those who help patients, families, and caregivers decrease barriers to prompt and quality health care including financial and psychosocial resources. In general, a navigation team consists of clinical and non-clinical members and are typically employed by a health care-, advocacy-, and/or community-based organization.⁸ Oncology patient navigation begins with prevention and detection and continues through diagnosis, treatment, survival, and end-of-life. 

The Enhanced Oncology Model (EOM) includes patient navigation as part of the infrastructure to support patients and improve care. In the EOM, navigation services include connecting patients to follow-up and support services, providing access to clinical trials, helping patients navigate the health care system to help “drive transformation and improve care coordination in oncology care by preserving and enhancing the quality of care.”⁹

Savings associated with navigation have also proven difficult to quantify. However, a study by Worland and colleagues found a total mean cost of care decrease of $459 PMPM for navigated group compared to non-navigated group.