Ben Jones, vice president, Government Relations & Public Policy, The US Oncology Network, addresses potential reform at the federal and state level that could accelerate the pursuit of value-based care in the community oncology setting.
Drug pricing reform and efforts to address pharmacy benefit managers (PBMs) are important federal, state-level actions to consider in driving towards value-based care in the community oncology setting, says Ben Jones, vice president, Government Relations & Public Policy, The US Oncology Network.
Jones will participate in a panel discussion during the second day of the 2022 Community Oncology Conference, titled, “Legislative Update From Capitol Hill: Cancer Politics & Policy in Washington, DC.”
In looking to the future of value-based community oncology, what factors warrant consideration for federal or state-level action?
Yeah, there's 2 things that are high on everyone's mind. At the federal level, first and foremost, it's all of the attention around drug pricing reform. Congress is eager to do something to address the rising cost of drug prices. It's also something that is supported politically on both sides of the aisle. Everyone agrees that we should do something to address drug prices, but it's the manner in which that's accomplished that's going to have the most impact on the future of cancer care delivery.
If they go in with a draconian measure that reduces practice and provider reimbursements without capturing all of the costs that the practices have to incur, then it's going to be very difficult to remain viable at the community level, which means care will shift into the hospital setting. And it's in the hospital setting where cancer care is about twice as much.
You've heard panelists throughout the COA conference talk about this disparity in reimbursement across sites of service. In Medicare, it's 2 to 1 on average, but in the commercial space, it's 3, 4 times as high in the hospital setting than it is in the outpatient community-based practice setting.
Anytime Congress tries to explore measures without contemplating the impact that those measures will have on community practices, it's going to lead to consolidation and there's no way to approach value-based care if you're pushing patients into the more expensive setting. So, that's one thing on the federal level.
The state level is equally as busy—there's going to be a lot of focus on who actually is making the decisions on care delivery at the state level, because we've seen a number of payers and PBMs, oftentimes taking the decision-making authority out of the providers' hands and into a middleman's hands to say: you can't have this course of treatment, unless you fail X, Y, and Z, or you can't have this course of treatment unless you get it from this place over here. They institute all of these utilization management protocols that candidly reduce access, impact adherence, and delay care, and all of those are likely to lead to negative outcomes.
So, what we have always said is that if we want to drive towards a future in value-based care, and payers are intent on supporting value-based care, then you have to give us the tools to treat patients—give providers the tools to treat patients in a way that they own the longevity of that patient, they know the treatment that's going to come because they know the outcomes, they've got access to timely care, they know the immediacy of these treatments, and they can take steps to make sure that adherence is absolutely followed through and that these drugs are administered in a timely manner. It's the right drug for the right patient at the right time. If not, you can't put them on the hook for outcomes in a value-based care world.