There is good news and bad news ahead for patients with cancer, oncology care, and the US healthcare system. The good news is that a phenomenal array of breakthrough cancer treatments, and possibly cures, are now on the market or in the development pipeline; many of those under development will be approved and launched on the market within a few years. The bad news is that these treatments will be very expensive. As a nation, we have no strategy, or even a minimal notional framework, of how we will pay for or afford them.

These cancer drugs and other treatments—many of them “targeted” therapies tailored to the specific genetics and molecular pathways of different types of cancer&mdash;have already garnered plenty of headlines in the popular news media. Drugs already on the market, such as the chimeric antigen receptor T-cell therapy Kymriah (tisagenlecleucel) and the programmed cell death-1 inhibitor Keytruda (pembrolizumab), have demonstrated very successful outcomes for some patients and cancer types. For example, they can produce added months of survival without any progression of disease or total remission for some patients with previously untreatable or relapsed cancers. Other new cancer drugs have proved less effective. One recent study for the American Society of Clinical Oncology (ASCO) showed that fewer than 1 in 5 recently approved cancer drugs met ASCO’s goals for producing “clinically meaningful survival outcomes” in patients.

Many news stories about targeted cancer therapies have featured the drugs’ lofty list prices, and legitimate questions have been raised about just how high these prices should be. But there is little doubt that these “ultrapersonalized” therapies constitute a new category of treatments that take years of complex research and testing to develop, are often painstaking to produce and administer, and are likely to be suitable for relatively small numbers of patients. Wherever the prices end up after negotiations among payers, manufacturers, and the healthcare providers that administer them, they will still be high.

A related, and possibly even more important, question: What will be these treatments’ value—to patients, to families, and to society? Many of these drugs are likely to be reviewed and approved by the FDA under expedited pathways for drugs that address unmet medical needs in treating serious or other, life-threatening conditions. For example, the FDA approved Idhifa (enasidenib), a targeted treatment for a type of acute myeloid leukemia, after phase 2 trials alone were completed.

 Such expedited approvals mean that at least some proportion of new therapies will not even have been tested in a broader phase 3 trial against standard therapies.

What’s more, many of these drugs will appear on the market quickly, long before health insurers have been able to factor the costs into their budgets or premiums for policyholders. For months, if not years, there will almost certainly be lingering uncertainties regarding which patients will be benefit from these drugs, let alone what the adverse effects and long-term consequences will be.

In the largest sense, it is important to establish broadly agreed-on and accepted frameworks for thinking about the value of such drugs so that we as a society can weigh the choices in front of us. Although groups such as ASCO and the Institute for Clinical Effectiveness Review have done important research and thinking to create frameworks for gauging the value of therapies, no framework to date has gained universal acceptance among all stakeholders.

 Because money isn’t unlimited, we will face trade-offs: investing more in lower-cost preventive agents such as vaccines, for example, versus high-cost cancer therapies. But even within a narrower context—deciding what drugs to pay for patients with cancer&mdash;we as stakeholders, and as a society, need some way of agreeing on the terms of engagement around their use. We need to devise frameworks for deciding which patients will receive these therapies, what expectations we should have of therapeutic performance, what we will attempt to learn about these therapies as we observe outcomes over time, and what we will pay.

In the absence of such broadly accepted frameworks, an alternative approach that has arisen is value-based contracting—a strategy in which payers and biopharmaceutical manufacturers agree to specific terms that tie payment to results.

 Also known as outcomes- based contracting, there are multiple varieties of these contracts, but the overall objective is to hold manufacturers more accountable for value than the typical drug sales arrangements that tie net prices to the volume of drugs purchased. Value-based contracts compensate manufacturers based on whether they obtain improved outcomes for patients from the use of drugs or better financial outcomes overall (for example, from lower rates of hospitalization because patients are healthier). In many instances, these contracts also involve shared financial risks between the parties: For instance, drug manufacturers may have to pay more if drugs don’t work as well as demonstrated in clinical trials.

As many as several dozen of these contracts have been reached between manufacturers and payers in recent years, and there is great appetite among manufacturers for negotiating more. These emerging strategies are not themselves a solution to the challenge of paying for high-cost oncology therapies or other medications, nor do they yet add up to a cohesive framework around value. But they do start the parties down the road to agreeing on the terms of engagement around value as they pertain to particular drugs. And in the absence of overarching frameworks for having discussions about value of high-cost therapies—especially in as fragmented a system of healthcare payment and delivery as that of the United States&mdash;they may be the best available option.

As important as these value-based contracts may be in setting the terms of engagement, however, they also pose innumerable challenges that must be overcome if they are

to become a standard feature of the healthcare landscape. My organization, the Network for Excellence in Health Innovation, described these challenges and issued a number of recommendations to address them in a recent white paper.

 To encapsulate the difficulty of some of these challenges, consider the example of Kymriah, the Novartis therapy approved by the FDA for use in patients up to 25 years old who have acute lymphoblastic leukemia that is either relapsing or refractory (ie, the cancer did not go into remission with other leukemia treatments).

The FDA approved the treatment in August 2017, after a phase 2 trial in which 63 patients showed an 83% remission rate within 3 months of infusion.

 To produce the therapy, a patient’s white blood cells are extracted through a special process in qualified hospitals, frozen, shipped to a special manufacturing facility where they are genetically reprogrammed, shipped back to the hospital, and reinfused into the patient after the patient undergoes low-dose chemotherapy to prevent the reengineered cells from being rejected.

At the time of approval, Novartis said that Kymriah would cost $475,000 for the onetime treatment for pediatric and young-adult patients.

 Some of the roughly 40 treatment centers that have been certified to offer the treatment have told payers that their “all-in” costs of treating a patient, including the cost of Kymriah, will top $1 million.

At the same time as the FDA issued its approval of Kymriah, Novartis also announced an agreement with CMS,

 presumably around the use of the therapy for patients on Medicaid. Under the agreement, Novartis offered the assurance that if a patient treated with Kymriah for this indication does not respond in the first month, there will be no charge for the drug to patients, and to payers, including Medicaid. CMS heralded the agreement and the approval of Kymriah as “reinforc[ing] our belief that current healthcare payment systems need to be modernized in order to ensure access to new high-cost therapies.” It promised to issue future guidance to explain how pharmaceutical manufacturers can engage in these and other innovative payment arrangements.

The parties said little else about the contours of the agreement, but reading the tea leaves, observers guessed that some commitments had been made about navigating around an important obstacle to value-based contracting: Government Best Price and Price Reporting requirements, the stringent rules that drug manufacturers must comply with as a condition of participating in federal healthcare programs such as Medicare and Medicaid. Complex calculations carried out under these federal requirements are designed to ensure that federal health programs—Medicaid, the 340B Drug Discount Program, and Medicare Part B Drug Reimbursement&mdash;benefit from discounts provided in the broad commercial healthcare market. These requirements stipulate a minimum discount for Medicaid of 23.1% off the so-called Average Manufacturer Price&mdash;the average price paid by wholesalers to manufacturers for drugs distributed to retail pharmacy, minus discounts&mdash; and locks in a similar discount for hospitals, health centers, and various safety-net providers under the 340B program.

For Novartis to have agreed to “no charge” for patients who did not respond within a month of treatment—without the “price” then becoming zero and triggering the same improbable price, or a deeply discounted one, for all of Medicaid, 340B, and Medicare Part B&mdash;it appears that CMS simply agreed that in such circumstances, no sale would be deemed to have taken place. But CMS has said nothing publicly since to confirm this interpre- tation, nor has it yet issued any of the promised guidance about how other innovative payment arrangements could legally be struck in the face of other federal regulations that pose similar obstacles, such as the Anti-Kickback Statute.

Aside from regulatory barriers to value-based contracts, there are other obstacles. Biopharmaceuticals and manufacturers alike would like the FDA to issue clear guidance about what will be permissible in the realm of communications from manufacturers about therapies that have not been approved and about uses of a given therapy that may not have been spelled out on the therapy’s label but are consistent with it (eg, data from patient-reported outcomes collected in the course of the drug’s FDA-approved clinical trial).

Enormous operational challenges will also accompany value-based contracting, chiefly around the collection, analysis, and use of data. Predicating a contract on patient outcomes means there must be a means of tracking them, not just in the immediate aftermath of the treatment but possibly for years. At no level, anywhere in healthcare, are current data tracking systems sufficient to accomplish this task. As the Blue Ribbon report of the Cancer Moonshot called for in 2016,

 we need to build the national cancer data ecosystem that is equal in dimension to the disease burden cancer imposes on society and the resources that we plow into cancer care.

Multiple steps are needed to build such a data ecosystem, including greater standardization and sharing of routinely collected cancer data, albeit within appropriate privacy safeguards. In a disease state as vast as cancer, it is also almost beyond comprehension why a core set of patient-centered and patient-reported cancer outcomes measures has neither been proposed, agreed on, or put into effect. Stakeholders should make adopting such a core measure set a priority. In addition to various quality-of-life metrics, given the costs of new cancer drugs, it will be critical to gather information on financial toxicity, or the problems that patients with cancer have that are related to their costs of treatment.

Given the complexities of value-based contracting, the barriers that stand in the way of it, and the operational difficulties that will accompany it, it would be easy to dismiss this approach as impractical and infeasible. But what other serious alternatives exist? These therapies will come onto the market; they will be useful and life-extending for many patients; and even if costs are heavily discounted from initial list prices, they will still be expensive. We need to hold these therapies up to the careful scrutiny that value-based contracting makes possible and then hold ourselves collectively accountable for spending resources wisely—to get appropriate treatments to the right patients, to understand the consequences, and to continue our research and development efforts to treat and cure cancer.

Susan Dentzer is the president and CEO of the Network for Excellence in Health Innovation, a nonprofit, nonpartisan organization composed of more than 100 stakeholder organizations across all key sectors of health and healthcare. NEHI’s mission is to advance innovations that improve health, enhance the quality of healthcare, and achieve greater value for the money spent. With offices in Washington, DC, Boston, Massachusetts, NEHI conducts independent, objective research and thought leadership to accelerate these innovations and bring about changes within healthcare and public policy.

Kumar H, Fojo T, Mailankody S. An appraisal of clinically meaningful outcomes guidelines for oncology clinical trials. JAMA Oncol. 2016;2(9):1238-1240. doi: 10.1001/jamaoncol.2016.0931.

FDA approves new treatment for leukemia. Genet Eng Biotechnol News. genengnews.com/gen-news-highlights/fda-approves-new-treatment-for-leukemia/81254750. Published August 2, 2017. Accessed February 2, 2018.

Dalzell M. Considerations for designing “value calculators” for oncology therapies. 

website. ajmc.com/journals/evidence-based-oncology/2016/ peer-exchange-spring-2016-oncology-stakeholders-summit/con- siderations-for-designing-value-calculators-for-oncology-therapies. Published May 12, 2016. Accessed February 14, 2018.

Rewarding results: moving forward on value-based contracting for biopharmaceuticals. Network for Excellence in Health Innovation website. nehi.net/publications/76-rewarding-results-moving-forward-on-value-based-contracting-for-biopharmaceuticals/view. Published March 23, 2017. Accessed February 2, 2018.

Dentzer S, Hubbard T. Value-based contracting for oncology drugs: a NEHI white paper. Network for Excellence in Health Innovation website. nehi.net/publications/79-value-based-contracting-for-oncology-drugs-a-nehi-white-paper/view. Published October 24, 2017. Accessed February 2, 2018.

FDA approval brings first gene therapy to the United States [news release]. Silver Spring, MD: FDA Newsroom; August 30, 2017. fda. gov/NewsEvents/Newsroom/PressAnnouncements/ucm574058.htm. Accessed February 14, 2018.

Nisen M. Read the fine print on the $475,000 price of a cancer breakthrough. Bloomberg Businessweek website. bloomberg.com/news/articles/2017-08-31/novartis-kymriah-cancer-drug-475- 000-but-read-the-fine-print. Published August 31, 2017. Accessed February 14, 2018.

Szabo L. Cascade of costs could push new gene therapy above $1 million per patient. Kaiser Health News website. khn.org/news/cascade-of-costs-could-push-new-gene-therapy-above-1-million-per-patient/. Published October 17, 2017. Accessed February 9, 2018.

CMS: innovative treatments call for innovative payment models and arrangements [press release]. Baltimore, MD: CMS Newsroom; August 30, 2017. cms.gov/Newsroom/MediaReleaseDatabase/ Press-releases/2017-Press-releases-items/2017-08-30-2.html. Accessed February 2, 2018.

Medicaid drug rebate program. Medicaid.gov website. medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/index.html. Updated November 24, 2017. Accessed February 14, 2018.

Cancer Moonshot Blue Ribbon Panel. National Institutes of Health website. cancer.gov/research/key-initiatives/moonshot-cancer-initiative/blue-ribbon-panel#ui-id-3. Published April 26, 2017. Accessed February 2, 2018.

Articles

Evidence-Based Oncology

It is important to establish broadly agreed-on and accepted frameworks for thinking about the value of high-cost cancer therapies, so that we as a society can weigh the choices in front of us.

Value-Based Contracting: Creating the Terms of Engagement Around High-Cost Cancer Therapies

Risk. This 4-letter word is problematic, but not for the usual reasons. In healthcare, the term, and more importantly the concept, is immensely important. Risk has very different meanings depending on whether one views it from a clinical or financial perspective. Clinicians deal with clinical risk analysis multiple times each day as we care for our sickest patients. But so too do healthcare policy experts and healthcare financial leaders, although how they use this terminology and view the concepts behind it is very different from how clinician providers do so. Herein lies a problem, and although it is not a new problem, it has been brought into focus recently: Policy makers are trying to engage clinicians in the transformation of the Merit-based Incentive Payment System (MIPS) into an advanced alternative payment model (APM) under the Quality Payment Program (QPP), which was formerly known as the Medicare Access and CHIP Reauthorization Act (MACRA).

To offer clinically and financially oriented readers a better understanding of how clinicians and healthcare policy/finance experts distinctly, and differently, define the concept of risk.

To highlight how issues related to the responsibility of controlling healthcare costs might also serve as an impediment to finding common ground on care- for-value programs.

The advent of MACRA has forced policymakers to require that physicians accept contracts that carry 2-sided financial risk in order to qualify as an advanced APM. Many physicians have been reluctant to enter into these agreements. Part of that reluctance may be related to physicians’ lack of understanding of the nuances of financial risk. But a more important problem may be whether physicians should be held responsible for the total cost of care.

Clinically, the concepts of risk and risk stratification are very important factors in how we triage and care for our patients. The same terminology is used quite differently when thought of in financial terms, however. As long as those 2 worlds or universes don’t overlap there is no real problem. But as mentioned earlier, more and more value-based care agreements include

financial risk terminology. When financial documents speak of risk, and these documents are read by clinicians, who are trained to understand clinical risk, they generally do not clearly differen- tiate the meaning of risk in this nonclinical usage. Because cost of care is then linked to financial risk, the misunderstanding of both issues leads to reluctance by physicians to collaborate. It is important to point out that this reluctance is not due to any lack of agreement related to the importance of value-related care but rather to confusion around the terminology and concepts under- pinning risk and cost of care.

Therefore, in this article, we will describe risk from both a clinical and financial point of view. You, the reader, are likely to be tasked with being the liaison between clinical leaders and financial leaders as they craft agreements that support transformation of care based on the quadruple aim, which builds on the strength and success of the triple aim by involving physicians in the design, development, and rollout of care improvement initiatives.

 This continued involvement of the frontline physicians and nurses increases the likelihood that a given quality improvement initiative will be successful once deployed. Some readers may think of the quadruple aim as a measure intended to lessen burnout. I think that occurs secondary to physicians and nurses feeling valued—feeling that they have been included in the design of a care improvement initiative that relies on their input and expertise and offers real clinical value for their patients.

This article does not try to serve as a primer on risk scores. To better understand the differences, I will provide examples of both clinical and financial risk systems. Table 1 lists some commonly used clinical risk scoring systems. All physicians, nurses, pharmacists, care managers, residents, and students use these daily in both the inpatient and outpatient settings. It is unlikely that nonclinical healthcare leaders are familiar with most of these. Table 2 describes 2 risk scores frequently used by health policy leaders:

Hierarchical Condition Categories (HCCs), developed by CMS, are used with Medicare Advantage programs and CMS initiatives like the Comprehensive Primary Care Plus (CPC+) initiative.3 They attempt to classify patients according to disease severity.

Chronic Conditions Hierarchical Groups (CCHGs) is another disease severity model, developed by Milliman.

Both the HCC and CCHG models use information from claims data in a retrospective analysis, while the clinical risk scoring systems use patient history, physical exam, laboratory, radiologic, intensive care unit and surgery monitoring data as real-time clinical measures. I encourage you to acquaint yourself with these various methodologies in order to understand the differences between clinical and financial risk models.

Both systems of risk measures are very important, yet they serve very different functions. The clinical models in Table 1 help the caregiver identify patients “at risk” for certain clinical problems and provide the caregiver the knowledge and flexibility to tailor the care plan, in real time, to minimize those occurrences. The systems in Table 2 offer a patient snapshot at one point in time, usually from a retrospective point of view, that helps the admin- istrative leadership predict the need and intensity of future care.

In my opinion, approaching the issue of risk based on patient care principles, and not issues solely related to cost or savings, could yield some common ground and would be more meaningful for caregivers.

Clinical risk analysis helps a caregiver stratify patients based on disease severity to better design each patient’s individual care plan, which increases the likelihood of their responding to various clinical interventions. Clinicians understand the problems of financial waste and duplicative testing and the benefits of evidence-based guidelines as we develop and improve our patients’ care plans. We understand how those factors impact costs for patients and their families. And what nonclinicians may not realize is that caregivers also understand that the high cost of care alone, or as deductibles or co-pays, often preclude the successful enactment of carefully designed personal plans of care because the patient cannot afford the medicine, the test, the surgery, or whatever therapeutic intervention is suggested. Over the past 8 years an initiative adopted by many physicians that incorporates concerns related to waste and inappropriate utilization of healthcare resources is the Choosing Wisely campaign.

 This initiative started out as a collaboration of a dozen physician healthcare organizations and has now grown to hundreds that share guidelines and best practices in an effort to improve patient care.

Certain ongoing care transformation programs from CMS—including CPC+ and the Oncology Care Model&mdash;incorporate cost into their clinical models. Unfortunately, those 2 programs presently involve only a small number of primary care and oncologic practices in the United States. However, as those programs continue and expected gains ensue, we will be able to share their processes of care and successful outcomes with other physicians.

Other care improvement initiatives are currently under way to benefit our patients and their families by improving clinical outcomes of care, including the CMS-initiated Accountable Health Communities (AHC) program

 (Table 3). Under AHC, 32 sites in the country will be working to operationalize concepts of care based on social determinants of health (SDH). This is germane to our present discussion because while physicians and nurses have long known of the importance of SDH, they did not take responsibility for including those challenges in their care plans because no processes existed that would allow for them to be improved. The frustrating reality, repeated over and over, was that we could improve our patients’ conditions while they were in our hospitals but upon returning to where they lived, their conditions often worsened, which resulted in their being seen again in our offices or in emergency departments or hospitals. Or, even more sadly, they would succumb to their underlying conditions for reasons that most of us would describe as nonmedical. Now, more and more providers understand that SDH might fall into the care plans as well. So we are, in effect, asking those 32 sites in the AHC grant to demonstrate to the rest of us how best to overcome these healthcare barriers. And so too it may be with issues of cost.

 Most physicians and nurses, outside the above-mentioned programs, do not consider cost and utilization aspects of care as fundamental issues that they are able to control. But this could change. Just like SDH are now being viewed as part of the patient’s care plan, so too might costs of care and utilization. This could happen if we are able to provide physicians and nurses with tools that would help them incorporate these aspects of healthcare into their patients’ plans of care.

 Once that occurs, then collabora- tively designing APMs that include 2-sided financial risk models may be more likely to succeed.

Most clinicians do not understand the broad concept of “1- sided” versus “2-sided risk”: that terminology is very different from concepts in the “clinical risk” realm. One option might be that healthcare policy/finance experts move away from the use of the terms 1- sided and 2-sided risk altogether and adopt other terminology to describe where cost and utilization fit into value-based care agreements. If we truly want to catalyze the move- ment of practices from a MIPS model to that of advanced APMs, we must accept that concepts and terminologies may be hindering our efforts.

But beyond clinicians and financial leaders not being on the same page on concepts of “risk,” a potentially greater problem is identifying who is ultimately responsible for the problem of the rising cost of care in our country.

One school of thought suggests that doctors should be more willing to accept the responsibility for that high cost of care. A phrase sometimes used by these proponents is, “Only God can make a tree and only doctors can order a test.” This overly simplistic idea may have some merit when viewing physicians as some type of global group; however, it holds little real-life value when thinking in terms of individual physicians or practices. According to this school of thought, physicians should accept the responsibility for the high cost of healthcare. One way to have a positive impact on the cost crisis would be for physicians to enter into finan- cial agreements where they are asked to assume “financial risk” for the total cost of care; terminology such as “2-sided risk” or “upside/downside risk” are often used in these agreements. It should not be surprising, though, that physicians are reluctant to partner in these agreements because physicians:

May not agree that they are able to control the costs attributed to them

Do not understand the meaning of risk in these settings

Reserve the use of the term “risk” to clinical care only.

Include caregivers early in the design phase of care improvement initiatives and provider-payer programs. In other words, design programs using the “Quadruple Aim” approach.

Convene providers, payers, patients, families, pharmaceutical companies, and information technology companies in the design of care improvement projects, following the lead of the CMS multi-payer care transformation models. One of the tasks of this group would be that of discussing the many aspects related to health- care costs and how best to lower those costs.

The answer to the question “Who is responsible for the high cost of care in this country?” may surprisingly be an easy one. You are. I am. We are. The responsibility, or blame, does not reside with any single component of our healthcare industry, and if we each act as representative only of one component it will be difficult to change the trending direction of the cost curve. However, we can take our cue from what providers are trying to do in the clinical sector—expand the concept of team-based care to better care for patients and families wherever they are, whether in the hospital, in our offices, in nursing homes, at the workplace, or (the most important “long- term care facility”) their homes. We should expand our concept of team in terms of healthcare policy. That expanded collective might be able to metaphorically get their arms around the multiple reasons why healthcare costs are so high. The blame does not rest only with the physicians, the hospitals, the pharmaceutical industry, the device makers, the payers, the patients or their families: The blame rests on all of the above.

In summary, we need to expand our concept of the healthcare policy team. That group should collaborate on the design of clinical care improve- ment initiatives that incorporate issues of clinical risk and ways to blunt the rising healthcare cost curve. We should avoid the use of the term “risk” in the agreements unless we are speaking to issues of clinical risk. We should be able to hold caregivers responsible for the appropriate use of healthcare resources as a part of patients’ care plans, but it is unfair to hold them responsible for total cost of care. That responsibility resides with the above-mentioned healthcare policy collaborative. Agreements that are part of the MACRA/QPP or other provider-payer agreements should reflect that shared responsibility.

Peter Aran, MD, is the incoming dean of clinical affairs and chief medical officer at the University of Oklahoma School of Community Medicine in Tulsa. He was previously medical director for Population Health Management in the payer sector.

Quality Payment Program. CMS website. qpp.cms.gov. Accessed February 23, 2018.

Aran P. To achieve a healthcare homerun, we need to tackle burnout. AthenaHealth website. athenahealth.com/insight/ to-achieve-a-healthcare-home-run-we-need-to-tackle-burnout. Published August 24, 2016. Accessed February 23, 2018.

Sessums LL, McHugh SJ, Rajkumar R. Medicare’s vision for advanced primary care: new directions for care delivery and payment. 

. 2016;315(24):2665-2666. doi: 10:1001/ JAMA.2016.4472.

Choosing Wisely. American Academy of Family Physicians website. aafp.org/about/initiatives/choosing-wisely.html. Accessed February 23, 2018.

Accountable Health Communities Model. CMS website. innovation. cms.gov/initiatives/ahcm. Updated January 8, 2018. Accessed February 23, 2018.

Alley DE, Asomugha CN, Conway PH, Sanghavi DM. Account- able health communities—addressing social needs through Medicare and Medicaid.

. 2016;374(1):8-11. doi: 10.1056/NEJMp1512532. 

Buntin MB, Ayanian JZ. Social risk factors and equity in Medicare payment. 

. 2017;376(6):507-510. doi: 10.1056/NEJMp1700081.

Billioux A, Verlander K, Anthony S, Alley D. Standardized screening for health-related social needs in clinical settings: the Accountable Health Communities screening tool. National Academy of Medicine website. nam.edu/standardized-screening-for-health-related-social-needs-in-clinical-settings-the-accountable-health-communities-screening-tool/. Published May 30, 2017. Accessed February 23, 2018.

Risk has very different meanings depending on whether one views it from a clinical or financial perspective.

The Risk Conundrum in Healthcare

The US healthcare system is in a state of crisis. Compared with other economically developed countries, the United States has been shown to be drastically overspending on healthcare while outcomes remain inferior. A 2013 report by the Institute of Medicine (IOM)—now The National Academies of Sciences, Engineering, and Medicine&mdash;described the US healthcare system as one that leads to “shorter lives, poorer outcomes.”

 While the United States leads in innovation for cancer therapies, the IOM report pointed out that the nation’s “increasingly chaotic and costly” cancer care system is in crisis and fails to deliver consistent care that is patient-centered, evidence-based, and coordinated.

Cancer care is among the fastest-growing segments of the US healthcare system, outpacing many other subspecialties. In the United States, total spending on cancer care has increased from $27 billion in 1990 to $124 billion in 2010, with spending projected to reach about $157 billion by 2020.

 Total costs of cancer care for the US population are predicted to increase across all phases of care: Cost drivers include technological innovation, rising costs of hospitalization, and a population-level increasing susceptibility to malignancy due to an aging demographic and increasing life span.

 Global spending on oncology and supportive care drugs reached $100 billion in 2014, with targeted therapy expenditures accounting for almost 50% of this amount.

 In the United States, oncology drug expenditures, excluding supportive care agents, increased by 18.0% from 2014 to 2015.

Along with payers, employers, and the government, patients, caregivers, and family members shoulder an increasing share of these rising costs due to changes in benefit design, which now combine higher out-of-pocket costs with rising premiums and deductibles.

Cancer treatment can have a substantial financial impact on patients and their families; in fact, financial toxicity has been cited as a contributing factor to adverse outcomes in patients with cancer.

One possible way to reduce overall cost, improve patient experience, and improve outcomes is to shift the focus of healthcare delivery away from volume and toward value. Patient-centered cancer care (PCCC) holds the promise of addressing these issues. The Oncology Care Model (OCM), developed by CMS’ Center for Medicare & Medicaid Innovation (CMMI), is a leading pilot that has been in place for over a year and seeks to test the efficacy of PCCC for Medicare beneficiaries over the next 5 years.

At Carolina Blood and Cancer Care Associates (CBCCA), we began exploring our practice’s journey from volume to value in 2013 by understanding the concept of patient-centered care and taking the steps necessary to acquire accreditation as a patient-centered specialty practice (PCSP) through the National Center for Quality Assurance (NCQA). Our path for NCQA accreditation primed us for the transition, as NCQA has many common denominators with OCM. Under the practice transformation requirements of expanded access leading to PCSP accreditation (a corresponding OCM requirement), we realized that expanded access would lower expenses, improve patient experience, and likely improve outcomes. We found that expanded access, including same-day appointments and weekend access, prevented unnecessary emergency department (ED) visits and hospitalizations.

As a part of the transition to PCSP, CBCCA started providing patients the convenience of same-day appointments and walk-in access. Our 2 clinic locations each have 2 slots per day reserved for walk-in patients. In addition to recruiting staff to accommodate additional patients, we created a triage process and pathways, and we trained both clinical and nonclinical staff to learn the relevance of these process changes. This initial investment is paying off in multiple ways. We have documented a significant increase in office visits resulting from phone triage (Figure 1). Initially, this seemed burdensome, as it required the allocation of additional resources. However, upon analysis of overall trends, we noticed a more than-50% increase in overall revenue from additional office visits over the 3-year period from 2014 to 2016 (Figure 2). For patients, same-day access and expanded access reduced the number of hours waiting in the ED, leading to both improved outcomes and quality of life (Figure 3), along with a reduced likelihood of after hours ED visits and hospitalizations (Figures 4-6). Additionally, patients were able to spend more time at home with their loved ones. Overall, patients and their caregivers received better quality of care. Patient satisfaction is being measured and data will be released later this year.

For payers, the increased quality of life for beneficiaries was coupled with a reduction in spending and a reduced likelihood of healthcare-associated conditions, as well as hospitalizations and visits to the emergency department.

OCM is the first major initiative by CMMI to pilot the transition from fee-for-service (FFS) toward value-based care. CMMI has been relatively flexible and accommodating of changes made to the program in response to stakeholder input. While OCM encourages oncologists to assume 2-sided risk, in which the practice is exposed to the possibility of both receiving shared savings and experiencing shared losses, the significant disparity between negative risk and upward reward is a barrier that has discouraged participating oncology practices from considering 2-sided risk. Additionally, fulfilling the data registry requirements in terms of data entry is both arduous and labor-intensive, and a high degree of technical expertise is required to do so.

Nevertheless, OCM is a first positive shift away from volume-based care to the value-driven path. Indeed, this transition into patient-centered care delivery will inevitably lead us down the path to fulfill the triple aim of better care, lower expenses, and improved patient experience. While Part B drug utilization is somewhat hard to regulate due to multiple factors, improving access to care— particularly, offering same-day access as well as slots to walk-ins&mdash;is low-hanging fruit, relatively easy to reach to help achieve the triple aim of healthcare reform.

Patient-centered care offers a definite option to address some of the challenges posed by ever-rising healthcare costs and deteriorating quality of care (Figure 7). The goal of value-based care in oncology is to improve the quality of care, while containing costs. Advanced APMs, such as the Medicare Shared Savings Program, 2-sided risk models, and OCM are examples of a shift away from the traditional volume-based FFS model. For the OCM, this objective targets Medicare beneficiaries through an episode-based payment model that financially incentivizes high-quality, coordinated care. In moving toward a value-based specialized care system, payers recognize and reward providers who proactively seek to improve the patient experience and health outcomes.

Kashyap Patel, MD, is president at Carolina Blood and Cancer Care Associates, based in Rock Hill, South Carolina. He is secretary of the Community Oncology Alliance and a trustee of the Association of Community Cancer Centers. Dr Patel is the past president of the South Carolina Oncology Society and the former chief of staff of Springs Memorial Hospital. Maharshi Patel, MBA, is practice administrator, CarolinaBlood and Cancer Care Associates. Asutosh Gor, MD, is board-certified inhematology, oncology, and internal medicine. and has been with CarolinaBlood and Cancer Care since 2004. Sashi Naidu, MD, is board-certified inhematology, oncology, and internal medicine and has been with CarolinaBlood and Cancer Care since 2005. Niyati Nathwani, MD, is board certifiedin internal medicine, hematology and medical oncology and has been with Carolina Blood and Cancer Care since August 2007. Radhee Kothadia, BS, is a student at Brody School of Medicine at Eastern Carolina University, North Carolina. Saheli Parekh is a student at North Carolina State University, Class of 2020. Eric Singhi, MD, is a second-year resident at Vanderbilt University School of Medicine who received his medical degree from the Medical College of South Carolina.

 In addition, Carolina Blood and Cancer Care Associates would like recognize interns Arya Patel, Resha Kodali, and Sagan Gor for their roles in practice transformation from 2014-2017. Patel is a senior at Ardrey Kell High School, in Charlotte, North Carolina; Kodali is a senior at the University of North Carolina, Chapel Hill; and Gor is a junior at Providence Day High School, Charlotte, North Carolina.

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de Souza JA, Yap BJ, Wroblewski K, et al. Measuring financial toxicity as a clinically relevant patient-reported outcome: the validation of the COmprehensive Score for financial Toxicity (COST). 

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One possible way to reduce overall cost, improve patient experience, and improve outcomes in cancer care is to shift the focus of healthcare delivery away from volume and toward value. Patient-centered cancer care holds the promise of addressing these issues.

Oncology Practice Transformation Helps Deliver Patient-Centered Cancer Care in a Community Oncology Practice

The US healthcare system is in a transition from traditional fee-for-service reimbursement to value-based contracts in cancer care delivery through oncology medical homes (OMHs), fostered by both CMS’ Oncology Care Model (OCM) and by commercial payers, such as Cigna and Horizon Blue Cross and Blue Shield of New Jersey (BCBSNJ). OMH models are designed to address all 3 parts of the triple aim: decrease the total cost of care while keeping quality and patient experience high. These initiatives have resulted in many innovative ideas to make practice transformation as smooth as possible.

Implementing these constructs requires the engagement of people, the creation or revision of processes, and the deployment of reliable technology, to make disruption

 as minimal as possible to patients and physicians, keeping routines as normal as possible, and to achieve the payers’ requirements. Disruption requires people in roles that can accelerate the changes or practice transformation,

 thereby providing the value in the new value- based payment world. The most recognizable accelerators in this transition are oncology nurse navigators (ONNs).

The role of the ONN was developed in the early 1990s by Harold Freeman, MD, who sought to diagnose cancer at earlier stages among underserved patients in the neighborhood of Harlem in New York, New York. Through a controlled experiment, Freeman showed that patients guided by a navigator after a suspicious cancer screening were more likely to follow through with biopsies—and in less time&mdash;than those who did not receive help.

 Over the next 2 decades, the nurse navigator’s role within the care team rose in importance

 even if fee-for-service payment models did not always recognize it.

ONNs provide the “constant” in what seem to be undulating waves of changes to workflows, the adoption of new technology, the near-weekly onslaught of new drugs, and the need to ensure every nuance of documentation is entered in discrete fields in electronic health records (EHRs) so the practice meets reporting requirements. A practice could have 1 ONN or a team of nurses who work with other clinicians and support staff to transform practices into OMHs. The ONN keeps the care team, including the oncologist, in rhythm, making sure the office is operating as smoothly as possible in the eyes of the patients and their families. The ONN can be dedicated to performing 1 or all the following functions, depending on the number of oncologists and patient volume in a practice:

Ensuring safe and reliable care is provided in the treatment and infusion rooms, by periodic reviews of policies and procedures and by visual checks utilizing Quality Oncology Practice Initiative safety standards,6 which ensure safe delivery of chemotherapy

Anticipating patient and family needs for new patients

Triaging and managing patients on the phone and making assessments and decisions using a technology-driven decision support of clinical pathways: for instance, whether to bring the patient in to avoid an emergency department (ED) visit or hospital admission, or to instruct the patient to take medications for adverse effects, with a computer notation to call back in 2 hours to make sure the patient will not go to the ED

Providing regular updates to referring physicians, such as primary care physicians (PCPs), on their patient’s prognosis, chemotherapy, and goals of treatment

The ONN must be a compassionate person, armed with clinical skills that nurses, of all healthcare professionals, have best developed: ONNs can “float” from uplifting conversations with patients and families about survivorship and community linkages, to staying solid as a rock when initiating end-of-life conversations. The ONN must explain the concept of Medical Orders for Life Sustaining Treatment, and must become an advocate to ensure that the patient’s wishes are honored throughout and at the end of the cancer journey. The ONN must also track which patients are due to come to the practice each day and which ones are eligible for clinical trials.

Care coordination, according to the Agency for Healthcare Research and Quality, is the deliberate organization of patient care activities among providers, and among provider visits, to ensure care is provided at the right place, at the right time, the first time and all the time.

 Sometimes it is called “managing the white spaces,” referring to the spaces between sites of care. Value-based reimbursement means 24/7 access to providers: not just ensuring that patients are adherent to oral therapy, but, to name a few examples, providing chemotherapy instructions to new patients who are of child-bearing age, serving patients whose cancer has progressed, holding the hand of a patient having another bone marrow aspiration, and calling back the spouse of a patient who needs to be told that “vomiting is expected and will pass.” It means hugging a mother who has just been told her child has cancer. This is cancer care delivery in a patient-centered OMH led by an ONN or a team of nurse navigators working in conjunction with oncologists.

At Regional Cancer Care Associates (RCCA), this is how we practice nursing, enabled by partnerships with commercial payers such as Horizon BCBSNJ and Cigna, as well as by participating in OCM. These payment models are still relatively new and may evolve. But nursing, despite challenges of shortage, burnout, and aging, is here to stay: for our patients, their families, and the communities we serve.

A recently announced pilot program between RCCA and Horizon BCBSNJ will provide ONN services from the time the patient is identified as participating in this program through survivorship care planning or palliative care services.8 The goal of the pilot program is to reduce care gaps by having nurses reach out to patients between treatments and identify issues that could lead to a trip to the ED. Horizon will pay a monthly management fee for the nurse navigators to manage each patient.

The pilot will be powered by Cota, an analytics platform based on real-world data that helps payers and providers optimize outcomes of individual patients while holding down costs.

 Once RCCA receives the lists of qualified patients from Cota, the RCCA practices are notified about these patients. The navigators then review the patients’ medical records and identify any gaps in care before the patient comes to the office. If the triage system shows that the patient has called in about any symptom, the patient is immediately contacted by the ONNs and either managed over the phone or brought to the office to be seen by the oncologist. The ONNs will utilize data from the EHR or analytic platforms to address any further gaps in care. The ONNs may access Jersey Health Connect,

a nonprofit health information exchange, to find out if the patient has been admitted to the hospital, or access Health Sphere, a platform developed by Horizon to create a comprehensive care plan for the patient.

When the patient comes to the office, the ONN spends time with the patient, sometimes even during treatment, to further assess the patient’s needs. This includes educating the patient and family members about the crucial process of calling the ONN about any issues the patient may be going through before they think of going to the ED. If the patient has any comorbid conditions, the ONN will also contact the PCP or specialist who is co-managing the patient to create full care coordination.

If the patient’s journey is moving toward palliative care, through markers such as stage, ECOG scores, pain scales, and frailty scores, the ONN will work with the oncologist and, where appropriate, the clinical social worker, to meet with the family and discuss the patient’s wishes. The ONN will help providing information regarding power of attorney, physician or medical orders for life-sustaining treatment, and a durable do not resuscitate order, if desired; the ONN will also help the family with the decision about placing the patient on hospice, when the time comes. 

Through the pilot, Horizon will track many measures about the patients, including time to treatment, medications used, unplanned read- missions within 30 days, number of ED visits, and number of inpatient admissions. By serving about 2000 patients through this pilot over 3 years, RCCA will help Horizon develop valuable best practices that will advance cancer care for patients across New Jersey.

Lani M. Alison, BSN, MS-HCQ, PCMH CCE, is vice president of clinical affairs for Regional Cancer Care Associates, which has 30 locations in New Jersey, Connecticut, and Maryland.

Main T, Slywotzky A. The patient-to-consumer revolution: how high tech, transparent marketplaces, and consumer power are transforming US healthcare. New York, NY: Oliver Wyman Health and Sciences; 2014.

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QOPI [Qualify Oncology Practice Initiative] Certification Program. American Society of Clinical Oncology Institute for Quality website. instituteforquality.org/qopi-certification-program-qcp. Accessed March 8, 2018.

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Closing care gaps in cancer care becomes focus on new collaboration between Horizon and RCCA [news release]. Hackensack, NJ: PRNews- wire; January 19, 2018. prnewswire.com/news-releases/closing-gaps-in-cancer-care-becomes-focus-of-new-collaboration-between-hori- zon-and-rcca-300585338.html. Accessed March 8, 2018. 

Caffrey M. Horizon, RCCA launch pilot to close care gaps between cancer treatments. The American Journal of Managed Care

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Homepage. Jersey Health Connect website. jerseyhealthconnect.org/. Accessed March 8, 2018.

Khemlani A. Horizon Health Sphere, an answer to UHC’s Optum, appeals to younger generation of docs. NJBiz website. njbiz.com/article/20170419/NJBIZ01/170419796/horizon-health-sphere-an-answer- to-uhcs-optum-appeals-to-younger-generation-of-docs. Published April 19, 2017. Accessed March 8, 2018.

Oncology nurse navigators provide the “constant” in what seem to be undulating waves of changes to workflows, the adoption of new technology, the near-weekly onslaught of new drugs, and the need to ensure every nuance of documentation is entered in discrete fields in electronic health records so the practice meets reporting requirements.

Oncology Nurse Navigators: Putting the Value in Value-Based Payment Models

Medicaid Expansion Led to Earlier Stage at Diagnosis of Testicular Cancer 

When Medicaid expansion began in 2014, under the Affordable Care Act (ACA), there started to be fewer uninsured patients and a shift to earlier-stage cancer at the time of diagnosis for patients with testicular cancer in states that adopted the expansion, according to findings presented February 9, 2018, at the American Society of Clinical Oncology Genitourinary Cancers Symposium, which was held in San Francisco, California.

“We all know insurance status is a key determinant of cancer outcomes,” said Xinglei Shen, MD, radiation oncologist, University of Kansas Medical Center. “People who don’t have insurance do poorly, and the ACA sought to improve outcomes by improving access to insurance.”

Shen and his co-author hypothesized that Medicaid expansion would lead to earlier diagnoses and more guideline-concordant treatment for patients with testicular cancer. They looked at the Surveillance, Epidemiology, and End Results (SEER) data from 2010 to 2014, which provides information on cancer statistics, and identified 12,731 cases of testicular cancer during the time period. The time frame of 2010 to 2013 was used as the pre-expansion group.

The expansion states included in the analysis were California, Connecticut, Hawaii, Iowa, Kentucky, Michigan, New Jersey, New Mexico, and Washington. Nonexpansion states included Arkansas, Georgia, Louisiana, and Utah.

Looking at Medicaid enrollment numbers for the SEER states that did not expand coverage, there was a modest increase in the amount of people on Medicaid versus a robust increase in those enrolled in expansion states, said Shen. The biggest change was seen in New Mexico, which had a 50.3% increase.

For insurance status at time of diagnosis, Shen et al found that in expansion states, there was a significant drop in patients who were uninsured at the time of diagnosis: from 8.7% to 4.3%, and a corresponding increase in the proportion of people enrolled in Medicaid: from 14.8% to 19.4%.

In nonexpansion states, there were no significant changes, according to Shen.

There was also an effect on the stage at diagnosis. In states that expanded Medicaid, 20.2% of patients had stage III cancer at the time of diagnosis, down from 27.1% before expansion. There was also a corresponding increase in the proportion of patients diagnosed at stage I, according to Shen. For states that did not expand coverage, 29.2% of patients had stage III cancer at the time of diagnosis, up from 23.2% before 2014.

Lastly, they look to see if there was an effect on quality of care, but the results did not indicate a significant difference. Shen concluded by indicating that longer-term follow-up is needed to study how Medicaid expansion would affect cancer outcomes and survival. 

Shen X, TenNapel M. Impact of Medicaid expansion on diagnosis and management of patients with testicular cancer. 

. 2018;36(suppl 6S; abstr 551) meetinglibrary.asco.org/record/157230/abstract.

Combining Radiation and Immunotherapy in Patients With Bladder Cancer 

"I think this is an exciting time in the treatment of bladder cancer and really oncology in general, because we’re learning to harness the body’s immune system against malignancies,” said Abhishek Solanki, MD, MS, assistant professor, Radiation Oncology, Loyola University of Chicago, during a February 9, 2018, session at the American Society of Clinical Oncology Genitourinary Cancers Symposium. The meeting took place in San Francisco, California.

While discussing the role of immunotherapy in patients undergoing radiation therapy for bladder cancer, Solanki emphasized that it’s also an exciting time because there’s a lot of preclinical data that have led to us evaluating this approach. Radiation is a local therapy, delivered for local purposes, like treating a primary tumor and in a bladder preservation case, he said. It’s also known that immune invasion is a critical hallmark of cancer and the main mechanisms by which tumors grow, progress, and metastasize.

According to Solanki, there’s emerging evidence that suggests that one of the reasons radiation is effective is because it is immune driven. Cytotoxicity related to radiation releases tumor antigens, which leads to activation of antigen-presenting cells and migration to the lymph nodes and, in turn, priming of T cells. There’s also a release of cytokines that lead to T-cell trafficking back to the tumor and an increased expression of major histocompatibility complex, class I, known as MHC1, within tumor cells. All of these things together lead to cell-mediated death, said Solanki.

However, radiation itself rarely leads to long-term immune memory and the ability to prevent late recurrences. Additionally, there’s emerging data that suggest that radiation can lead to upregulation of programmed cell death-1/programmed death ligand-1 (PD-L1) and regulatory T-cell infiltration into the tumor cell, suggesting that there may be some immunosuppressant effect of radiation.

“This brings us to the hypothesis that we can combine radiation immu- notherapy to improve local control through radiosensitization by bypassing those resistance mechanisms,” said Solanki. “Potentially, by combining these modalities, we can improve systemic response and have long-lasting immune memory when we combine these agents.”

Solanki cited what he said is one of the only studies of bladder cancer specifically looking at the question of the combination of radiation immunotherapy. Investigators implanted bladder cancer tumors in mice and then separated them into 2 groups: one treated with radiation alone and the other treated with radiation and an anti—PD-L1 antibody. With radiation, there was a decrease in the size of the tumor, but it started growing again shortly after. In the combination group, there was more durable and more significant tumor control. 

“This leaves us with 2 clinical questions,” said Solanki. “The first is with our traditional paradigms of bladder preservation and definitive chemoradiation therapy. Can we use immunotherapy to improve the outcomes? On the flipside, for patients who have metastatic disease who are being treated with checkpoint inhibitors and for palliation, can we use local radiation to augment that effect and give them more mileage with the available therapies?” Although there is not a lot of data available for bladder cancer, Soalnki said that we can turn to some non—small cell lung cancer (NSCLC) studies that can provide leads on benefits observed.

In the PACIFIC trial, patients with stage III NSCLC receiving definitive chemoradiation with cisplatinum-based chemotherapy were randomized to be administered either placebo or up to 12 months of durvalumab. Investigators found a clear difference in progression-free survival (PFS) that favored the durvalumab group. Also, in the metastatic setting, in the KEYNOTE-001 study, UCLA investigators assessed their NSCLC cohort and found that radiation prior to pembrolizumab was associated with PFS and overall survival.

“Bringing things back to bladder cancer, one of the reasons why it’s hypothesized that immunotherapy’s so successful in NSCLC is because of the high somatic tumor mutation burden, and bladder cancer is right up there,” said Solanki. “And we already have a track record of success with immunotherapy in bladder cancer with [Bacillus Calmette-Guerin] for nonmuscle invasive disease and checkpoint inhibitors for metastatic disease. So I’d argue that bladder cancer is the ideal setting [in which] to investigate the combination of radiation immunotherapy.”

Solanki explained that while there is a lot of clinical and preclinical rationale to combining immunotherapy and radiation for bladder cancer, there’s a lot we don’t know, and the unknown at this time is bigger than the known.

He concluded: “I think it’s up to us, as a community, to find out exactly how best to combine radiation with immunotherapy to augment the effects of both modalities.”

Docetaxel Plus Hormone Therapy Improved Quality of Life, Cost-Effectiveness in Prostate Cancer 

The addition of docetaxel to first-line long-term hormone therapy in patients with prostate cancer is associated with improved quality of life (QoL) and cost-effectiveness, according to study results presented February 8, 2018, at the American Society of Clinical Oncology Genitourinary Cancers Symposium in San Francisco, California. 

Nicholas James, MBBS, PhD, Queen Elizabeth Hospital, presented results from the STAMPEDE trial, which looked at patients with M0 and M1 disease. The primary outcome of the trial was overall survival, and secondary endpoints included failure-free survival (FFS), progres- sion-free survival (PFS), metastatic PFS, skeletal-related events (SREs), toxicity, cost-effectiveness, and QoL.

“Docetaxel produced a very consistent improvement in FFS across the whole trial,” said James. “The other thing that was very consistent across the whole trial was a 40% reduction in symptomatic skeletal events.”

The researchers used a standard model-based approach, explained James. All patients started hormone sensitive and progressed to M0 castration-resistant prostate  cancer(CRPC) or M1 lymph node disease, CRPC with bone metastases, CRPC with bone metastases with a SRE, or CRPC visceral. The STAMPEDE trial data were used to determine how much time each patient spent in each cate- gory and what were the QoL implications. The researchers also assessed cost-effectiveness.

Because patients with M0 disease have a 40% delay in the time to relapse, the patients getting docetaxel up front spend more time hormone sensitive than patients in the control arm, said James. Thus, the onset of CRPC M0 or M1 lymph-node only disease is delayed, and patients live fewer months with these conditions or with bone metastases, with or without an SRE. This correlates to a longer period of relatively good QoL and less time with poor QoL. For the metastatic setting, the same effects were observed. Patients spend more time in the hormone-sensitive state, which means less time with the factors that harm your QoL and increase your costs, said James.

“For metastatic patients where there’s a survival advantage, not surprisingly you see a quality-adjusted life years [QALYs] gain as well,” said James. “In other words, the benefits of not relapsing, not having SREs, wipes out the quality-of-life penalty that you incur from your up-front chemotherapy.” 

The same effect was seen in patients with M0 disease. Although there wasn’t a robust survival advantage in this setting, there is still a QALY gain.

Over the course of the trial, treatment with docetaxel didn’t change end-of-life costs substantially. But docetaxel costs increased, management costs generally went up, and the costs of other life prolonging therapies went up. However, there’s been big changes over the duration of the trial with the emergence of androgen receptor—targeted therapies, said James.

Coverage from the American Society of Clinical Oncology Genitourinary Cancers Symposium, held February 8-10, 2018, in San Francisco, California

April 2018

Value-Based Contracting: Creating the Terms of Engagement Around High-Cost Cancer Therapies

The Risk Conundrum in Healthcare

Oncology Practice Transformation Helps Deliver Patient-Centered Cancer Care in a Community Oncology Practice

Oncology Nurse Navigators: Putting the Value in Value-Based Payment Models

Conference Coverage: ASCO Genitourinary Cancers Symposium

Conference Coverage: Association of Community Cancer Centers

Medical World News: Managed Care Updates

From the Editor in Chief: A Game of Risk