Andrew L. Pecora, MD, CPE: We talked a little bit about Oncology Care Models (OCMs). I’d like [to ask for] your views of the medical home in the context of OCM and [in the context of] private payers using the medical home [model]. But also, let’s throw another factor in, and that is risk-based contracting where physicians are going to take downside risk.
In New Jersey, we’ve started, and we’ve been doing this successfully now for 2 years, prospective bundles where you get 1 check for the entirety of care. Right now, there is no downside risk, but it’s going to move to downside risk. We know with the Medicare Access and CHIP Reauthorization Act (MACRA), the CMS (Centers for Medicare & Medicaid Services) wants to move to downside risk (not just in oncology). If you could address it in its totality, it seems that we’re moving from the early stages, which is basically getting electronic medical records, having a nurse in your office, and having your office available, to this mid-range thing where you’re doing extra things—which is kind of OCM. But, ultimately is it your opinion that the game is to get to downside risk? And what do you think about that?
Brenton Fargnoli, MD: So, I think, as you mentioned, through MACRA, there is certainly a trend to downside risk being at least shared by providers. In terms of the medical home, there are key components that will be important to managing that risk. One is having kind of a quarterback who can coordinate the care and ensure that the best care is getting delivered directly throughout the neighborhood, as opposed to just the clinic. And the second is really engaging the patient in that care— engaging their views as to the type of care that they want, whether it’s technology or human interaction; a place where once the patient moves beyond those 4 walls, they’re still a part of that clinic. And so, I think, that’s a really important piece from the medical home part.
In terms of taking downside risk and sharing risk and contracting, there’s a long way to go in terms of the data. Payers have had claims data for tens and tens of years, and clinicians have had clinical data for centuries. [But] those 2 have rarely come together in a cohesive manner.
So bundles that are going on today in oncology are very broad. Lung cancer would be a bundle, for example. But the claims data doesn’t have small cell versus non-small cell, stage I versus stage IV. For practices to take on that risk, they need to be able to understand the cost of those particular patients, as well as how they’re performing [in 1 practice] compared to other practices.
And so, CMS has been providing claims data to practices as part of the OCM so they can start doing this. A lot of the payer models we spoke of, whether it’s Aetna or others, have a component where the quality measures and other measures are a way to provide clinical data to the payer. They can incorporate stage now, they can incorporate non—small cell and small cell histology, into those bundles. But, we have a long way to go to bring those together and provide insights where a clinician can responsibly take on that risk.
Andrew L. Pecora, MD, CPE: I couldn’t agree with you more. In our bundles, we are way even past. First of all, it is a marry [marriage] of the clinical data, the laboratory data, genomic data, and the claims data. There’s no other way to do it, you’re absolutely right. It allows the application of precision medicine at scale to do that.
And, now, let’s ask Dr. Sagar to weigh in.
Bhuvana Sagar, MD: I personally think that the care coordination component, the emphasis on care coordination, is what leads to the success of the medical home model. Having the patient at the center and focusing on the other key tenets around it: education of the patient, making sure there’s a shared-decision component, making sure they’re heard, and [helping them to understand] what the best treatment option out there is, as well as what their options are, or what their opinion is.
You know, what do they want from that particular cancer treatment? Is it curative therapy or is it palliative therapy? Does the patient really understand what’s going on with all of the challenges of dealing with this new diagnosis? So it is a very challenging time for the patient, but [we want them to] understand things a little bit better. Each patient comes to the journey at a different point in time and [with a] different level of understanding.
So, I think it’s the medical team’s responsibility to judge where the patient is, how much information do they want to know, and how much information are they able to handle. But I think education is a key component of the success for them once they understand what the treatment is, and what side effects to expect. If it’s a known side effect, how do they manage it? Those are all key components of trying to drive the total cost of care.
Once the patient understands, and if their symptoms are managed really well with early palliative care, do they still choose the same therapeutic options in their fourth line of therapy or fifth line of therapy when there’s not a lot of evidence supporting those therapies? So what outcome are we looking for? And building off of a patient who understands what their outcomes are, and what their treatment options are, is what is going to drive this.