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Hope and Some Skepticism Whether Oncology Payment Models Will Work

Allison Inserro
Coverage from the Institute for Value-Based Medicine® session held in Nashville, Tennessee.
A little over a week before CMS revealed some of its thinking on the future of oncology value-based care,1 oncologists and others who crowded into a Nashville, Tennessee ballroom at the end of October shared their thoughts, successes, and frustrations with the current Oncology Care Model (OCM).

However, at certain points during the latest installment of the Institute for Value-Based Medicine®, an initiative of The American Journal of Managed Care®, it was hard to tell if the physicians and healthcare executives in the room were thinking about January 2020, or January 2021.

Next month, of course, is when oncology practices participating in the OCM must decide whether to accept 2-sided risk. Come January 2021, CMS plans to start Oncology Care First (OCF), the successor to OCM; on November 1 it released its request for information.

“It sounds scary, but I hope you leave tonight inspired because I think we’re ahead of the game on this,” said Stephen M. Schleicher, MD, MBA, co-chair of the meeting, an oncologist at Tennessee Oncology, and chair of the Quality and Value Committee of OneOncology, a network of community oncology practices.

There are 3 things the oncology community should focus on, said Schleicher:

  • Understand the models in depth because value-based care (VBC) is here to stay,
  • Work to educate payers about how to improve their models to make sure that cost control does not come at the expense of patients, and
  • Optimize care coordination to prevent avoidable emergency department (ED) visits and hospitalizations, facilitate end-of-life care planning, and avoid unnecessary tests and pharmaceutical use.

“Think before that pet scan if you need it, think before that expensive drug, if we have a biosimilar instead,” he said, offering up examples.

Darrin Gordon, who is widely credited with turning around TennCare, the state’s $10.5 billion Medicaid managed care program, described how initially it took him a few years to “lean into” the idea of VBC and value-based purchasing (VBP).

As part of his presentation, he reviewed a VBP framework, created by the Health Care Payment Learning and Action Network, which created a pathway for describing different alternative payment models. The 4 categories range from Category 1 (fee for service); Category 2 (FFS, and a link to quality and value); Category 3 (alternative payment models built on a FFS architecture); and Category 4 (population-based payment).

Even after Gordon says he “fully embraced” VBP, it was necessary to change his thinking once again.

“I’ll just say this: as a self-diagnosed value-based purchasing zealot....where I literally thought we should buy light bulbs on a value-based purchasing agreement, after going through it, you discover there is a lot of stuff that value- based purchasing isn’t suited for.”

At the same time, “There’s a big belief in the industry that we don’t arrive [to VBP] until we get everyone to Category 4. I don’t think that’s right either.”

While the categories may seem like a continuum, with some organizations falling  into Category 2 or 3 because it works best for them, the only thing you won’t find, he said, is anyone defending fee-for-service (FFS). There is plenty of evidence that FFS does not work, even if the evidence on VBP is not yet conclusive.

Instead, fueled by rising healthcare costs, there is an overwhelming sense from payers that “we have to try something different.” Indeed, oncology is spread among all 4 categories—commercial, Medicare, Medicaid, and the exchanges.

In Tennessee, Gordon said he saw wide variability in cost from provider to provider, as much as a 3 to 6 times cost difference that couldn’t be explained.

“We needed more tools to incentivize quality improvement,” he said.

However, he said he didn’t want to tell doctors what to do or how to do it. Rather, he said, “What I wanted to do was to create a dynamic to where the provider could start asking different questions, should be asking different questions.”

Vanderbilt University, at the time, had a tool to connect patients to doctors via text, even though they didn’t get reimbursed for it, but they are large enough that they could absorb the cost. It was at that point, he said, where he realized he could use the state’s Medicaid program to change reimbursement for physicians who had already told him, “We know what we need to do for patients, and we also know we won’t get paid for doing those things.”

“That was a big driving force for this,” he said.

Referring to a concern raised sometimes from patient advocacy groups who are concerned that VBP agreements can be used to restrict access to certain treatments, he said that was not the case at all. “Actually, it’s just creating different questions that the providers themselves, that clinician, is going to ask themselves in ensuring that they have the best possible outcome for that member.”

When VBP is working at its highest level—meaning when payers, providers, and patients are all working together to improve health—he said, “Quite frankly, a lot of discussions about prior authorizations are meaningless,” adding, “I don’t care as much, because you’re fully at risk.”

While Gordon said he believes that VBP will remain firmly in the future landscape, the next speaker, Michael Kolodziej, MD, FACP, vice president and chief innovation officer at ADVI Health, was decidedly not as upbeat. “I’m going to disagree with just about everything you just said,” he told Gordon, just before comparing commercial payers looking at oncology practices as to the way Willie Sutton looked at banks—because that is where the money is.

“How did we get into this mess?” Kolodziej asked.

“The cost of taking care of cancer patients in the US has exploded largely as a consequence of the cost of drugs that have brought great value for our patients, but at a significant price and the rate of the trend so far exceeds the average person’s income that nearly everybody says in unsustainable,” he said, launching into a review of the first alternative payment models in oncology.

When he was in charge of oncology strategies at Aetna, he participated in the OCM when it launched.

“As a care delivery model, the OCM is awesome. But Medicare did not go into this to improve the quality of cancer care. They went into this to save money,” he said. “And the payment is based on this goofy methodology that they developed. And I think anybody who spent time thinking about this recognizes that the model is way too complicated, just way too complicated.”

So after 4 performance periods, what has been learned? There are problems with various parts of the model, Kolodziej said, and it has been adjusted several times. Yet, even as savings increased over the 4 performance periods, in his view, 90% of the participating oncology practices have no idea why they generated savings.

“This model does not fix their pain,” he said, because it does not address the cost of drugs.

When he was at Aetna in a partnership with Texas Oncology, using the ClearPlus pathway saved 20% of the cost of care. He attributed that to the use of pathways, not Aetna’s medical home. He also challenged the notion that payers consist of only of health insurance plans. It’s the employers who are the payers, he said, and they are complaining loudly to health plans.

“We have a long history [over] last 20 years of paying too much for stuff that doesn't work. We got some stuff now that works. That makes it really challenging,” he said, citing a study which said there was no link between the marginal added benefit of new drugs and the launch price.2

Referring back to the next iteration of the next oncology care model to come out of the Center for Medicare and Medicaid Innovation (CMMI), Kolodziej was pessimistic. “I think that they cannot have a care model in which 85% of oncologists in the US cannot participate. And that's what OCM is right now.” Alternative payment models are just not cutting it, he said.

Harkening back to the idea of using new tools to drive improvement, Robert Daly, MD, MBA, of Memorial Sloan Kettering Cancer Center (MSKCC), explained how they are using predictive data analytics to improve care for patients by meeting CMS quality measures for avoiding preventable hospitalization due to 10 conditions: neutropenia, fever, pain, dehydration, anemia, pneumonia, sepsis, nausea, and diarrhea.

With proactive care and increased communication, these can be managed as an outpatient. Why is this an issue? Daly said patients on active treatment have 1 hospital admission and 2 emergency department (ED) visits per year; about 50% of those ED visits, and 40% of those admissions, are related to toxicities from their treatment.

This is for 3 main reasons, he said:
  • Patients managing side effects at home and not being equipped to do so
  • Patients assuming little can be done to help them and they don’t seek care until symptoms get worse
  • Variation in communication between patient and clinician.

“So as anyone who has treated cancer patients knows, they’re not just coming in with 1 symptom, they’re coming in with clusters of symptoms, “ Daly said.

Daly said the work of Ethan Basch, MD, MSc, on the effect of patient-reported outcomes on survival and quality of life, inspired the MSKCC pilot project. The 2017 study found that proactive self management resulted in better outcomes for patients compared with standard of care, including a 30% improvement in quality of life, 7% fewer ED visits, and surviving 5 months longer.3

The pilot project, called InSight Care, combines patient-reported outcomes (PROs) with data and proactive care and case management to prevent hospitalizations and ED visits, keeping the patient “in sight” of the provider 24/7 through the use of digital technologies.

Data analytics identifies the highest-risk patient, meaning the 25% of new antineoplastic patients most at risk to arrive at MSKCC’s urgent care center. The risk model helps providers stratify patients within the clinic to know who is going to be at high risk for a potentially preventable visit within the first 6 months.

The model takes data from the electronic health record, including laboratory tests, home medications, comorbidities, and psychosocial data and combined them to create a risk score. But doctors are also allowed to add patients to the high-risk group using an override feature.

In addition, Daly said the design of the interface that the patient sees was designed in such a way that patients completing assessments would have low barriers to completing them. The questions have binary answers (ie, yes or no); the patient can provide more details as well as use an avatar to provide a visual description of where they are having symptoms. The MSKCC staff sees the alerts and can tell instantly if the alerts are mild, moderate, or severe. If the team needs to see the patient, they can do it through a specialized video portal, instead of making the person drive into New York City from the suburbs.

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