Coverage of the Institute for Value-Based Medicine session with Zangmeister Cancer Center, Columbus, Ohio.
Value-based care is often discussed in the context of oncology, where care does not come cheap and its associated toxicities—both financial and clinical—can have a substantial impact on patient quality of life. But efficient collaboration among primary care providers, oncologists, and other care team members is crucial to ensure patients with cancer receive the best possible treatment for their specific disease.
Expert presenters and panelists at The American Journal of Managed Care’s Institute for Value-Based Medicine session on September 14, 2023, held in partnership with Zangmeister Cancer Center in Columbus, Ohio, discussed value-based care in the context of primary care and oncology as well as the ways in which providers and practices can work together to improve care for patients with cancer while mitigating financial toxicity.
“As much as we advanced clinically—we have great treatment options for patients, we’re advancing with research and clinical experience, which is wonderful—I think we all are facing a lot of concerns about the other side of things and the actual system itself and how we navigate that. There’s a lot of unknowns and lack of transparency in terms of understanding it,” event cochair Jeanna Knoble, MD, medical oncology and hematology managing partner at the Mark H. Zangmeister Cancer Center, said. Knoble hosted alongside Christine Pfaff, RPh, senior regional director of operations at American Oncology Network.
Knoble explained that although clinical skills are honed in medical school and in practice, the health care system itself poses a different set of challenges for clinicians. She raised a key question that would be discussed throughout the event: How can practitioners come together to align on common goals and provide optimal care for patients within a health care system that they cannot control, and how can this be done in a value-based way?
The Politics Affecting Value-Based Cancer Care in Oncology
Nick Ferreyros, managing director of policy, advocacy, and communications at the Community Oncology Alliance (COA), kicked off the discussions with an overview of the political dynamics that affect the oncology space overall and trickle down to value-based care.
The current political landscape is a divided one, Ferreyros explained, but consensus between parties is needed to get things done. And although politicians at every level have run campaigns on reducing high health care costs in the United States, often placing the blame on “big pharma” in vague terms, drug prices remain the most important health care issue. Ferreyros specified that drug prices are not the same as drug costs based on list prices alone and that entities such as pharmacy benefit managers (PBMs) abusing their roles have been recognized as part of the problem in recent years.
“There’s a lot of partisanship, but where you’re really starting to see movement in action is at the state level,” Ferreyros said. “Because that’s happening. That is really pushing the agenda federally, so it’s a great thing to see, because there’s a lot of these things that bother everyone—PBMs, insurance regulations, practice regulations, how the patients experience their care—and that makes a big difference.” The state level is where bills affecting oncology and value-based care are most likely to pass, he added.
Ferreyros listed a host of issues that COA has on its radar, which all come into play in discussions of care cost and improving both patient and practitioner experiences in the community setting.
One issue directly affecting community oncology practices has been a decrease in Medicare payments for cancer care services. When adjusted for inflation, there has been a 33.8% decrease in such payments over the past decade, Ferreyros explained. Although reimbursement for procedures has decreased by 5.4%, the compounded interest of inflation has increased by 28.4% in the same period.1
Payment stagnation and cuts combined with a slew of public policies that adversely affect community oncology practices have fueled consolidation, closures, and financial hardship among independent practices. Over the past 2 decades, Ferreyros said, chemotherapy services delivered at independent community oncology practices, which carry much lower costs than those administered in the hospital setting, have decreased by 64.3%.2
Oncology drug shortages have also been making headlines in recent months, and this is another area where bipartisan consensus is a must for change to take place. Patients have faced delayed or cancelled care, and Ferreyros points to extreme reimbursement and low pay for generic sterile injectables as a root cause.
“There is a financial problem in generic sterile injectables, and nobody in Congress wants to be seen as increasing the pay for generics manufacturers,” Ferreyros said. “But if you never do that, then nobody’s ever going to invest in the manufacturing capacity, and we’re never going to solve this problem, and this vicious cycle will continue year after year.”
The IRA, PBMs, and Value-Based Care Under the OCM and EOM
The Inflation Reduction Act (IRA) is another point of interest for oncology stakeholders, because it gives the government the ability to negotiate drug prices. The first 10 Medicare Part D (oral) drugs being targeted were released in August, and that list included the oncology drug ibrutinib (Imbruvica).3 Part B drugs (injectables) will be negotiated on a longer timeline, but these negotiations have a few drawbacks, Ferreyros explained.
For one, providers are caught in the middle, with these negotiations affecting average sales price (ASP). Medicare reimburses providers at a rate of ASP plus a 6% add-on fee meant to cover the costs of administering the drug, and a COA analysis found that the negotiations could result in a 47% cut to add-on reimbursements for Part B oncology drugs at community practices on average.4
Notably, the IRA drug price negotiations will not prevent large hospitals from marking up drug prices for patients who have commercial insurance or who are uninsured to make up the difference. Furthermore, the negotiations do not affect PBMs or prevent site-of-service markups, which may reduce the impact these negotiations have on the cost of health care for patients with cancer.
Still, he said, with the speed at which the government operates, several lawsuits already pending, and the upcoming 2024 presidential election, it remains to be seen how the IRA and drug price negotiations will play out.
Among community oncology practices, another issue in recent months has been CMS quietly reinterpreting rules that previously allowed the delivery of oral drugs by practices; now, this is considered self-dealing, and therefore a Stark law violation, meaning patients must pick up their medications in person at a practice.
“It is an incredible hardship for patients who have to travel on a regular basis to refill their medications. Also, a very strict interpretation of Stark law is that they can’t have friends or family [pick up] those medications,” Ferreyros said. “It is probably the most fired up I have ever seen our network of practices get over an issue.” COA has already brought a lawsuit against the government over the reinterpretation and is working with Congress on a legislative solution while the lawsuit is pending.
Another major cost driver in health care has been the dealings of PBMs, which are already in the crosshairs for reform. Ferreyros pointed to a recent report from the US Government Accountability Office—a watchdog organization run by the government itself—that found PBMs are marking up drug prices for plan sponsors rather than achieving the goal of lower negotiated prices from manufacturers.5
Ferreyros closed with a comparison between the Center for Medicare and Medicaid Innovation (CMMI)’s Oncology Care Model (OCM) vs the new Enhancing Oncology Model (EOM), both of which are voluntary alternative payment models. Although 122 practices participated in the OCM, which was introduced in 2016 and ended in 2022, just 44 practice groups opted into the EOM by its launch on July 1, 2023.6 The biggest concern for practices, Ferreyros explained, was the immediate entry into 2-sided risk for those participating in the EOM.
The EOM also includes parameters aimed at improving health equity and reducing disparities, such as screening for social determinants of health (SDOH). However, Ferreyros voiced concern about these increased requirements under the EOM, with minimal resources given to practices to address the issues that may be uncovered through screening patients for SDOH.
“These models have a lot of uncertainty and a lot of things you cannot control, particularly in the drug prices. And so immediately jumping right into the deep end with 2-sided risk could be very detrimental to practice finances,” Ferreyros said. Of the 122 practices that participated in the OCM, just 30 opted into the EOM, with the majority being larger practices with multiple sites. Ferreyros noted that during the OCM, practices dropped out during performance periods, and he expects the same during the EOM.
Eliminating Waste to Maximize Value
At the heart of value-based care initiatives is a desire to take a patient-centered approach to treatment, improving outcomes while reducing costs and financial toxicity. Kristin Oaks, DO, Agilon medical director at Central Ohio Primary Care (COPC), and Jennifer Sturgill, DO, hospitalist and inpatient medical director of population health at COPC, shared their insight into the importance of value-based care initiatives in the primary care setting.
COPC is a physician-owned, independent primary care group serving more than 450,000 patients at 87 practices across 6 counties. It has a value-based care enterprise that now encompasses about 30 partners and focuses on health care for older patients. Agilon is a nationwide platform and partner to COPC and other practices that provides practices with insight into data to facilitate improved care while mitigating costs.
“I think of value-based care as the elimination of waste,” Oaks explained. “And when you’re approaching that from a primary care perspective, that might be the underutilization of some care.” One example is the Diabetes Prevention Program, which helps patients at risk make lifestyle changes to prevent diabetes, she said. “We underutilize that vs what people typically think of, which is the overutilization of some services, surgeries, etc. I think what [value-based care] really is, though, is a payment model that supports outcomes over quantity.”
Sturgill echoed the sentiment, noting that a big focus has been matching the intensity of services to medical necessity. In her practice as a hospitalist, Sturgill makes it a point to consider the best place for a patient to be treated from both the medical need and value perspective.
One challenge that COPC has worked to overcome in reducing waste has been keeping providers within a large network aligned and directing patients to the appropriate treatment setting.
“Health care as a whole is fragmented, and that’s true even in our own independent practices,” Sturgill said. “We have a lot of very independently thinking providers. Everybody does their own thing, and we’re trying to get them on the same page. How can we care for this patient together?”
Part of the strategy is having hospitalists present in emergency departments that data show admit too many patients and building relationships with emergency department physicians to help direct patients to the appropriate program and follow-up, Sturgill said. Such initiatives improve the patient experience by reducing hospital admissions but also reduce unnecessary health care spending in the hospital setting.
COPC also created its Comprehensive Home & Palliative Care program as a way to provide at-home care to patients with chronic illness or patients with cancer who may otherwise be repeatedly admitted to the hospital. Physicians, social workers, advanced practice providers, and nurses work to manage these patients, have goals-of-care discussions, triage patients, and get hospice involved when needed.
“Primary care physicians and oncologists have very limited time in the office where [they] can have these conversations, so we can have our provider go out and have a longer conversation with the family in the home setting—and that makes a huge difference,” Sturgill said.
Oaks also emphasized the fact that just because a treatment is expensive does not mean it constitutes waste, both in primary care and especially in oncology. Rather than focusing on things such as imaging or tests being redone when aiming for cost reduction, she emphasized the importance of measures such as reducing hospitalizations or readmissions through postdischarge follow-ups and chronic disease management.
The Value of Care Coordination for Patients With Cancer
A multidisciplinary approach and associated care coordination are key to improve both the patient experience and clinical outcomes. Knoble, whose clinical focus is breast cancer, and Kristine Slam, MD, FACP, a board-certified surgeon specializing in breast surgery at Central Ohio Surgical Associates, discussed their experiences collaborating to improve patient care over the years.
Knoble first gave a primer on the importance of a multidisciplinary care team, emphasizing the need for communication between physicians both within and across practice groups at different sites and with distinct electronic medical record systems. There are various useful methods of formal and informal communication, with a weekly tumor board to discuss new cases being one of the ways in which oncologists, surgeons, and radiologists discuss the most appropriate treatment plan for each patient.
“It’s important from a patient perspective too, because they want to make sure that their doctors are all aligned on what the plan is,” Knoble explained. “You can’t go to one office and get one plan and then go to another office and get another, so it’s important that we communicate.”
Supportive services are also paramount to optimal patient experience and outcomes, with nurse navigators, genetic counselors, physical therapists, counselors, and other professionals assisting patients as the treatment plan is executed. Every patient is different and will therefore have their own unique care team and plan, Knoble added.
A well-planned treatment regimen aligns not just with guidelines but also provides the most value to patients. Using medical, radiological, and surgical treatments at the appropriate intensity level based on risk-stratification tools and patient preferences is important to minimize financial burden and toxicity throughout treatment. Knoble also reiterated the financial implications of treating patients outside the hospital when possible, because although outcomes have been found similar, costs can be nearly double when patients receive care in hospital-based settings vs community oncology practices.
Slam echoed the need for a patient-centered approach based on guidelines to ensure that patients receive the right treatment with as little quality-of-life and financial impact as possible. She noted that approximately 85% of patients with breast cancer will leave the workforce for some time and approximately 40% will spend their life savings during the first few years of treatment. Most patients, even those with insurance, are not aware of just how much care will cost—even after insurance—until discussing it with their physicians, she added.
Treating patients in line with evidence-based guidelines, de-escalating care when appropriate, and performing procedures in the community setting when possible are measures Slam takes to deliver patient-centered treatment in a value-based way.
“We’ve been able to do outpatient-based breast cancer surgery for years. I think there is still a very big misperception that patients need to be in the hospital for breast cancer surgery, and they do not—it’s been safe and effective for probably more than 10 years now,” Slam said. “The site of service [cost difference] is astronomical in surgery.”
Although hospital-based surgery is still needed in some cases, the vast majority can be safely performed in an outpatient ambulatory setting for a fraction of the cost, she noted.
Defining and Executing Value-Based Care
In a final panel discussion moderated by Knoble, presenters Oaks, Sturgill, Slam, and Ferreyros were joined by Ben Martin, MD, urologist at Central Ohio Urology Group; Taral Patel, MD, medical oncologist at Zangmeister Cancer Center; and Sameh Mikhail, MD, medical oncologist at Zangmeister Cancer Center.
Ferreyros spoke to the need for alignment on the definition of value-based care. With various stakeholders looking for value—from patients and payers to PBMs and even the government—coming to a consensus on value in health care is a challenge in itself, he explained.
Martin and Slam agreed that value to patients comes in many forms, including the overall experience at a community practice compared with the hospital. In the community setting, for example, a 9 AM surgery appointment will likely happen as planned, whereas surgeries in the hospital setting often face delays that can add to patient stress.
Patel resurfaced the topic of waste reduction as a path to less costly care and success under CMMI alternative payment models, including the EOM.
“Everybody thinks value-based care means we need to give substandard care. I don’t think that’s the case,” Patel said. “We look at how we can avoid [waste], and we find out a lot of times that what we need to achieve to succeed in the EOM we can do with very few tweaks.”
One such change is dosing patients based on weight, as occurs in phase 3 clinical trials, vs giving every patient the same dose. By following protocols outlined in trials and opting for weight-based treatment, he said, resources can be saved. “We’re finding a lot of things that we’re doing [that are] wasting money may not be improving outcomes.”
The panel reiterated the need for communication between providers as well as earning how each member of a care team treats their patients. Getting into a rhythm of communication with other members of a patient’s care team, especially in cancer care, should be routine and can significantly reduce duplicate work and duplicate costs.
“By design, most community practices are very agile,” Mikhail added. “And this makes care coordination happen organically—that we run into to each other at the hospital, where we work in a single office or limited number of offices. We talk with each other all the time, and we have a lot of influence to change the way things work. As a result of this agility, care coordination happens much more efficiently.”
To conclude, Patel emphasized a point made throughout the evening’s discussions: value-based care varies by patient and may still entail expensive treatments. He offered the example of immunotherapies, which come at a substantial cost but have been shown to reduce spending elsewhere by decreasing hospitalizations among patients with lung cancer.
In the end, the panel agreed, the same question that the event began with remains: What is the definition of value to the various stakeholders in oncology, and how can value-based care initiatives accommodate all parties? Although the discussion is ongoing, more work needs to be done.
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2. 2020 Community Oncology Alliance Practice Impact Report. Community Oncology Alliance. April 24, 2020. Accessed October 3, 2023. https://bit.ly/3LvLIVC
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4. Sullivan M, Tripp A, Isaiah E, Burnett B, Diskey R. IRA Medicare Part B negotiation shifts financial risk to physicians. Avalere. November 29, 2022. Accessed October 2, 2023. https://avalere.com/insights/ira-medicare-part-b-negotiation-shifts-financial-risk-to-physicians
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6. Caffrey M. Final tally lists 44 practices in EOM, but it’s complicated. The American Journal of Managed Care. July 12, 2023. Accessed October 2, 2023. https://www.ajmc.com/view/final-tally-lists-44-practices-in-eom-but-it-s-complicated