Produced by Jaime Rosenberg

Richard Snyder, MD, Executive Vice President, Facilitated Health Networks; Chief Medical Officer, Independence Blue Cross

With more novel, costly therapies being approved and patients being responsible for more costs, how do you think this will impact the prevalence and popularity of value-based agreements?

I think it will absolutely increase the speed to value-based care and also the kinds of arrangements that we will see going forward. There are quite a few creative ideas emerging. Amongst them, the Blue Cross Blue Shield Association has a number of direct contracting models to eliminate the need for a provider to invest in the cost of a medication, [which will] thereby gain perhaps somewhat of a discount and facilitate the patient care delivery without incurring as much out-of-pocket costs for the patient.

How do value-based agreements benefit all stakeholders, including providers, patients, and payers?

If they’re done correctly, a value-based contract should benefit all 3. So, I’ll give you a few examples. First of all, from a patient perspective, we can define the benefits to reward patients with lower out-of-pocket costs if they go to a Blue Distinction Center or a center of excellence to get their care, and by steering them to such a location, they’re virtually guaranteed to have better clinical outcomes at a lower cost. That is the basis for the Blue Distinction Centers program that the Blue Cross Blue Shield Association has been promulgating in and around things like [chimeric antigen receptor] CAR T-cell therapy and Luxterna and other expensive drugs.

Typically, they reward the payer with lower total cost of care, and oftentimes a warranty in the event the medication does not effectively control the diagnosis. Obviously, that is a good thing since a large proportion of the care today is being paid for by employer groups through self-funded arrangements, and these very, very costly drugs that are emerging from the pipeline put a significant stress on their [profit and loss statements], so from a payer perspective and ultimately our customers, the employer group, it helps to control costs and ensure quality outcomes and reward us with a warranty in the event the outcome is not optimal. In the case of the provider, a lot of these arrangements do not require the provider to pay out the cost of stocking or storing these medications until a patient is waiting for them. With some of these programs, precertification barriers or limits can be reduced, since they’re very unusual circumstances—rare diseases where the medication otherwise wouldn’t be used. So, I think there are plenty of reasons why the member&mdash;the patient, the payer&mdash;the ultimate customer the employer group or the government, and ultimately the provider delivering the service can benefit from value-based contracts.

How important are population health management and coordination of care in value-based contracting?

They’re actually integral to value-based contracting. When we do episode of care payments, we are paying for a period of time and everything that happens in that period of time, so it’s critically important that the right patients are chosen for that episode, that there’s extremely good coordination to prevent leakage out of the system of care to other systems, and ultimately that patients adhere to any medication regimens that they’re prescribed and that post-acute care when the patient goes home for a period of time, that’s included in the episode, is well managed so they don’t bounce back to an emergency room or a hospital or end up having a complication that could have been otherwise avoided if we had been monitoring them more closely. 

Stephen Schleicher, MD, MBA, Medical Oncologist, Tennessee Oncology

In today’s world, we have technology, whether it’s video capabilities or Bluetooth-enabled monitoring devices to determine whether patients are adhering to their treatment plans and whether they’re having any early signs of a complication that could result in a readmission to the hospital or emergency room or avoidable testing and treatment. 

What are your thoughts on the proposed Radiation Oncology Model and the fact that CMS wants it to be mandatory?

The big hype right now is this proposed radiation oncology bundled payment. This would be the first true bundled payment to come in oncology. The [Oncology Care Model] OCM is an episode-based payment, but it is not  a bundle, and then the other experiments like Medicare’s [Bundled Payments for Care Improvement], the comprehensive joint replacement model—both had nothing to do with oncology. So far in oncology, outside of [Merit-based Incentive Payment System], the OCM was voluntary, so this is a big change in oncology to have a mandatory payment model, and as we’ve seen in OCM, there are unpredictable consequences of the methodology, such as the novel therapy drugs coming out after the baseline.

So, in my opinion, I’d prefer a voluntary model where groups that are excited about being on the cutting edge can be a part of that and help us learn where the challenges are in bringing a bundle to radiation oncology and then perhaps make it mandatory in the future, based off the initial feedback.

How does the implementation of high-cost, novel drugs into clinical practice after the baseline period cost calculations further add to the challenge of lowering costs under OCM?

This remains a challenge since the baseline period was up until 2015 and we had this, really, immunotherapy boom happen after that. So, it is a challenge and Medicare does a great job trying to predict what costs should be based off these new novel therapies, but we have some data that was presented at [the 2019 American Society of Clinical Oncology annual meeting] ASCO and is going to be published shortly showing that this is still not a perfect methodology to account for these, so I think understanding those challenges and trying to understand the risk that those challenges have on us going forward is important. I will say performance period 4, which included the first half of 2018, was when immunotherapy came to the front line of non-small cell lung cancer, so it was kind of a test case for the model, and I think I was pleasantly surprised that the prediction had been better than expected when we got our performance period 4 results. 

Nina Chavez, MBA, FACMPE, Chief Operating Officer, New Mexico Oncology Hematology Consultants, Ltd

Now that we are a few years into the OCM and other value-based models, have community oncologists become better at practicing the business of oncology?

It’s a difficult question in the sense that community oncology [aren’t] businessmen. Doctors don’t go to medical school to get a business degree, and, unfortunately, in our healthcare environment, if you’re going to be an independent practice, you have to understand the business of medicine that you’re in. I think that the OCM over the past couple of years has helped us look at things that we didn’t really think of from an oncology perspective.

You’re always looking at the patient first, you’re always looking at that patient outcome, but now we have to look at the total cost of care, we have to look at that patient engagement piece—not just saying that we did it but also documenting it and having those documented interactions, which is something more for the payers than, really, the patient.

So, I do think that oncologists have become better businesspeople.…They’ve had to in order to survive in this environment and be able to take care of their patients in a better way.

With therapies like CAR T-cell therapy entering the market, will reimbursement present significant challenges to providers?

CAR T…I was talking to my doctor about this because I’m not clinical, and I want to make sure I got her opinion, and she said that with CAR T, the insurers are not paying for it right now; we don’t know what’s going to happen. It really should be happening in a hospital, but if you’re not partnering with your hospital and you’re trying to do it in an independent practice, it’s not going to be easy.

I think from a cost perspective, we don’t know what the market’s going to do; we don’t know what the payers are going to do. We do know that we can’t get that medication—we can’t get CAR T therapies very easily in community oncology. We can’t even get it from the [group purchasing organization] we currently have.

You have to go through a certain specialty, and it is very costly, so I think that remains to be seen. It’s something that we’ll have to kind of see how it goes.

Lee Schwartzberg, MD, FACP, Executive Director, West Cancer Center; Chief Medical Officer, OneOncology

The US Preventive Services Task Force (USPSTF) recently updated its recommendations for 

 screening and testing and included women with a history of several cancers and women with ancestry associated with the mutations. What are your thoughts on this?

Who should be screened for genetic testing for cancers is an ever-evolving issue, and we recently saw the USPSTF come out with a new recommendation. To me, this was very interesting, because they tend to be a very conservative group, and they actually got ahead of some of the other guideline committees by mentioning that all women who have a personal history of breast, ovarian, or other cancers should be tested. So, we’re starting to see this movement toward universal testing. We’re not quite there yet, but this is a broadening of who should be tested.

Testing for germline mutations for hereditary cancers is getting cheaper all the time. It’s getting easier to talk about, although we still need our genetic counselors, and we need a workflow that works with this because genetic testing doesn’t just affect our patient, it affects the whole family. So, it’s a little different concept from the way we take care of patients. I think there’s more and more comfort with disseminating this information, so I strongly endorse that recommendation. Not every payer has agreed to that yet, but it’s definitely moving in that direction.

The reason this is important is that up to 5% to 10% of women who have cancer, one of the female cancers, will have a mutation, and that’s a pretty substantial number when you’re dealing with a quarter of a million breast cancer diagnoses per year. So, this old sort of arbitrary “do triple-negative breast cancer if they’re under 60”—there’s a lot of arbitrariness in who we’re defining should be tested. The broader we make it, the better it is.  

What are your thoughts on USPSTF leaving men out of its updated recommendation for 

Jeff Patton, CEO, Tennessee Oncology; President of Physician Services, OneOncology

Well, I believe that all men who have breast cancer, for example, should be tested. About 10% of them will have a hereditary risk factor, usually a BRCA1 or BRCA2 gene. The number of genes that contribute to hereditary breast or ovarian cancer is broadening, so we’re learning more over time as we move from the very high penetrant cancer syndromes to somewhat less, but we’re learning a lot, so I think men will be included in the near future.

What are your thoughts on the Community Oncology Alliance’s (COA’s) proposed OCM 2.0? Does it address concerns that providers have with the current model?

COA has had a lot of input and a lot of help from Tuple Health and Kavita Patel [Brookings Institution] to help address the flaws in the current model, but also it includes some things that should probably have been in the initial model. Again, [I have] a lot of confidence with what’s coming out of COA. I just hope we can get them to implement it.

Is there concern or anticipation among providers about what might come after OCM ends?

I think [there is] less concern about what might come after OCM. It’s clear that we’re going in that direction with value, and so we have confidence that OCM will be iterated and 2.0 will be better than 1.0 was. We have a fair amount of influence on that. I’m on the COA board, so I have a lot of input into the COA feedback. We also use Tuple Health as our consultants; they have the ears of CMS. I actually know personally the soon-to-be-named director of the Center for Medicare and Medicaid Innovation, who is really smart and will give us a lot of confidence in building on the successes, and I think OCM has been a success. There are some flaws, like in any initial system, but we have confidence that 2.0 will be better than 1.0. 

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AJMC®TV interviews let you catch up on what’s new and important about changes in healthcare, with insights from key decision makers&mdash;from the clinician, to the health plan leader, to the regulator.

AJMCtv October 2019

Michael J. Birrer, MD, PhD, Director, O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham

How well is oncology research being integrated into clinical management of patients? How can it be done better?

Well, [in] my long, illustrious experience in oncology, I’ve sort of seen it all, and I think that in the late ’70s, ’80s, and I’ll even go into the ‘90s, so much of oncology development was empirical. We would take drugs off the shelf that essentially had been shown to damage DNA or showed some cytotoxic effects against the tumor cells and then we would bring that in an empiric way into the clinic. I think that sort-of almost unscientific approach explained at that time why things moved so slowly.

Why were we stuck on carboplatinum-taxol for ovarian cancer for so long? Because we were doing this, yet another cytotoxic agent from off the shelf, from the lab, into the clinic. That’s completely changed, and to answer the question directly, I think we’re bringing laboratory discoveries into the clinic in a much more efficient and rational way than we ever have in oncology. What I’ve seen change in the last 5 or 10 years has been just astonishing. And there’s multiple advantages of this. So first of all, the transit time is quick. Whereas it used to take 20 years to develop a drug, we’ve now had some drugs approved in the phase 1 setting. That’s certainly true in lung cancer.

So, I can’t say that we’ve gotten it down to 3 to 5 years, but we probably are developing drugs effectively under the 10-year limit, which is half of what it used to be. 

The second issue, [which is] really important for patients, and I tell my patients this, the science is so robust that when the drug gets into the phase 1 [trial], you now have a drug for which the chance of a success is high, the chance of efficacy is higher, and the chance of toxicity is lower.

So, I used to have an old adage. I’d tell my patients that I would never recommend them go for a phase 1 trial if it was outside of a 50-mile radius because traveling all that distance for something that was unlikely to work and maybe toxic wasn’t worth it. It’s completely changed now….

Catherine M. Diefenbach, MD, Hematologist—Oncologist, NYU Langone Health

Now I have patients fly in for a phase 1 trial because it’s a novel combination, because there’s a lot of really interesting science behind it, and its chance of being successful is much higher than it was 10 or 15 years ago.

Can you discuss the importance of reducing toxicity in the treatment of lymphoma? How does this affect patients’ overall health, in addition to quality of life?

I think in general, it’s really important to use the new drugs that we’re discovering that are targeted and to combine them intelligently with standard chemotherapy. Because we know that intensive chemotherapy regimens, while very effective in the first line for patients who have [a] short response or refractory disease, are generally not effective in later lines, unless you go to really high doses.

And most patients don’t tolerate this well, especially if they’re older or if they have significant toxicity. So, trying to take existing chemotherapy at lower doses and combine it with targeted strategies or immunotherapy is a way to both circumvent the higher toxicity of cytotoxic chemotherapy and rely on tumor biology to be smarter, rather than more aggressive, about targeting lymphoma.

Roy S. Herbst, MD, PhD, Chief of Medical Oncology, Yale Cancer Center

There is a lot of research into predictive biomarkers in cancer. How well is that research making it into practices and actually being used with patients who can benefit?

It’s incredible what’s happened now with personalized therapy of cancer. Targeted therapy for lung cancer, we now have 8 or 9 different markers, which if you have them, different oncogenes can allow a physician to give their patient a targeted drug, which might have a response rate upwards of

50% with much less toxicity than chemotherapy.

These are being used, [but] the problem is some of the drivers are rather new, such as RET, NTRK, MET, and we’re still not in all places screening patients for these markers. So it’s going to be very important that people watching this, whether patients or physicians, ask, “Is the profiling test that’s being done at your center or your hospital, that you’re getting as a patient, including all the newest drivers for lung cancer?” Because only if you look for them can you then try to find the therapy either in your local providers office, or if not, since some of these agents are still rather new, there are clinical trials running at many sites.

The nice thing about 2019 is clinical trials really occur almost every place in the United States. So, these things are beginning to get into common practice. At my institution at Yale, we have a center in downtown New Haven, we have 12 to 13 sites around Connecticut, we’re making sure everyone uses the profiling system.

Andrew H. Ko, MD, Colorectal and Gastrointestinal Cancer Specialist, University of California San Francisco

And then there have to be discussions. And things like this [interview] will help people to discuss and learn and understand the importance of these new markers and how to match for the right drug.

You helped write the National Comprehensive Cancer Network (NCCN) Guidelines Insights for pancreatic adenocarcinoma. What was the treatment recommendation for these patients?

NCCN guidelines are a panel of experts in a particular field who gather together to analyze data and interpret them to help guide recommendations for how we manage and treat patients with a particular disease. I’m on the guidelines panel for pancreatic cancer. So, again, some of the specifics in terms of choices of chemotherapy and uses in the advanced or metastatic setting or the adjuvant setting, those are based—as much as possible&mdash;usually on randomized data.

In terms of the latest updates, I think probably the most impactful one is the importance of at least considering genetic testing [in] all patients.

In the past, we used to be a little bit selective in whom we would recommend that for, but now it’s almost a universal recommendation that we at least consider doing genetic testing. By that I mean, even if someone doesn’t have a provocative family history of cancer, we should think about doing genetic testing on those individuals to see if they have any hereditary susceptibility genes.

The classic one would be someone [who] has a germline BRCA, either BRCA1 or especially BRCA2, mutation because not only does that have particular implications for screening family members, but now we know that it actually has very substantive therapeutic implications for the patients themselves, with the use of PARP inhibitors and a greater sensitivity to platinum agents, for example. 

I think that’s a very important piece that perhaps goes underrecognized still in the community, and that’s a little different from just tumor-based molecular testing, which also, actually we believe, should be done or at least be thought of on a more consistent basis. And that’s basically looking at any mutations or genetic alterations within the tumor itself, so sematic mutations or genetic changes, because what I usually tell patients is any information is good to have. It’s not always actionable, but if we happen to find the patient who has evidence of microsatellite instability, or an NTRK fusion, well we have very specific treatments for those situations, and we have clinical trials available sometimes for patients with other mutations [who] are selected for those specific mutations. So I think doing that as much as possible, doing that kind of molecular profiling, is also something that should be considered routinely. 

Despite there being a growing number of therapeutic options for pancreatic cancer, a recent study found one-third of these patients don’t see a medical oncologist and more don’t receive treatment. Why do you think that’s the case? Can anything be done to improve those numbers?

I think pancreas cancer, because it’s historically been felt to be a pretty dismal disease in terms of prognosis and patients faring poorly, I think there’s perhaps been a sometimes-nihilistic philosophy that some providers even still have despite our growing array of options for patients. So, I think part of it is that education piece for providers, but also for patients and families themselves. I think aggressive symptom management—because sometimes when a patient presents, the thought is, “Well, they’re not a candidate for treatment because they have such severe pain or because they’re losing so much weight”&mdash;if we can aggressively manage those cancer-related symptoms, it may afford the opportunity to at least offer them some treatments. We recognize that our current treatments may help some individuals a lot, some maybe just a little, and some not at all, but I think just giving them that opportunity, if they’re well enough, to even try…I always want that option to be available to patients, and I think that’s perhaps one of the main challenges

Produced by Jaime Rosenberg

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AJMCtv October 2019

AJMCtv Interviews: ASCO 2019