Value-based Considerations of CDK4/6 Inhibitors in the Treatment of Metastatic Breast Cancer - Episode 12
An assessment of the global cost of care for patients with breast cancer—namely individuals with metastatic disease being treated with CDK4/6 Inhibitors.
Bruce Feinberg, DO: We touched on this notion of guidelines and pathways. We’ve touched on step edits and tiers that payers used. And I want to begin with that payer story again, because one of the aspects as we think about value-based care, which has been kind of the background theme of much of the conversation, has to do with how you assign cost. It’s been pushed in the OCM [Oncology Care Model] to be global cost, and global cost even includes for those participating practices—not just the cost that they’re responsible for in terms of that they prescribe, but cost incurred for that patient even if they’re non-oncologic care and for patients who choose to go to an emergency department [ED] when they maybe could have gone to the office, or choose to go on a weekend, et cetera.
I’m curious, from a payer perspective, can you assess global cost of care due to the costs that are incurred as a result of toxicities attributed back to the drug? Is it too complex to do it? Can it be done? Is it done?
Steven Peskin, MD, MBA, FACP: We do look at total medical expense and total cost of care. That is 1 of our key factors with our clinical partners. At the most fundamental level it works with our large health systems and independent practice partners that are in total-cost-of-care models for an attributive population. So this would be for cancer care, pulmonary, rheumatologic disease, diabetes, hypertension, all that.
In cancer care, we’ve limited total cost of care to being for cancer care. We’re not looking to have oncology groups, in a sense, accountable for managing or co-managing, say, psoriatic arthritis. So that the total cost for the cancer episode, to your point, Bruce, would include an ED visit; low acuity, non-emergency ED visit; or moderate acuity ED visit that could have been avoided had the Oncology Group had better clinical pathways and same-day appointments, like appointment scheduling, just as we see in the primary care medical home, the oncology medical home, which we stood up with one large group.
And as we’ve focused on the episode-based payment models simultaneous to the oncology medical home, and breast cancer has been the leading area of cancer, so, Bill and Joyce, very appropriate for today’s discussion, that’s been the area where we’ve done the most deep data science analytics and defining what goes into the episode, what gets excluded, and what the outlier points are.
Then it really becomes incumbent on clinicians like you were when you were in practice, Bruce, or Joyce and Bill, to make decisions that are, first and foremost, in the best interest of the patient, but then also through the lens of total cost of care, which, as you mentioned, Bruce, includes the toxicities, the side effects, the potential need for hospitalization.
I was hearing from someone today, a primary care internist like myself, about something from Canada, that treats mucositis very well. That he was talking about a friend of his, actually a physician with stage IV breast cancer.
So we do look to our clinical partners to make those complex clinical decisions. What we do as a payer, Bruce, is tee up information using our staff programmers, our data scientists to help our clinical partners, she or he, to understand where those costs reside. And then making, as I mentioned before, Bruce, we are not in the guideline business. We have chosen not to go that route. Some payers have and I’m not saying good, bad, or indifferent about that. But we chose not to do that and rather working with our clinical partners to navigate and make decisions about when or when not to do PET [positron emission tomography], CT, or which supportive therapies to use in the treatment or management of cancer.
Bruce Feinberg, DO: And in this episode design, are episodes then paid as a bundle payment?
Steven Peskin, MD, MBA, FACP: Great question—today they are retrospective. So it’s fee-for-service, and the clinical partner will see where they ended up at the end of the episode. Did it have a defined link? Six months, 9 months?
In the future state, we are in discussions with a prospective episode, so the claims that will be dropped, using an insurance term, claims submitted will be zero dollar paid. The claims are needed to track the utilization resource use, and to be able to look at that prospectively, retrospectively. But the cost will be based on an “X” number of dollars for that episode. So we are moving sometime this year into the prospective payment.