Dr Samyukta Mullangi Discusses How Structural Issues in Cancer Care Systems Impact Health Disparities

Samyukta Mullangi, MD, MBA, oncology fellow at Memorial Sloan Kettering Cancer Center and incoming medical director at Thyme Care, spoke on financial toxicity, heterogeneity of cancer, and other complex factors in oncology care systems that may perpetuate disparities in health care outcomes and delivery among patients.

Oncology is characterized by complex patient needs, heterogeneity, and cost, with high risk to payers and providers, and ensuring high value cancer care warrants consideration of several factors, said Samyukta Mullangi, MD, MBA, oncology fellow at Memorial Sloan Kettering Cancer Center, and incoming medical director at Thyme Care.


What lessons have you learned from your experience and research as it pertains to how care systems can perpetuate health disparities and inequities in oncology, and how will this influence your work in your role at Thyme Care?

That's a great question. I've been interested in alternative payment models and value-based efforts in oncology for years. While value-based care (VBC) had its start in primary care and discreet surgical procedures, such as joint replacements, I would say only in recent years has it started to evolve into specialty care, and that's partly because of the realization that while primary care physicians are the linchpins to the entire system, much of the spend actually occurs in specialty clinics.

Oncology itself is characterized by very complex patient needs, a fair degree of heterogeneity and cost, high risk to payers and providers, and represents the most expensive disease category for payers. The total cost of cancer treatment in the United States is projected to near a quarter of a trillion dollars by 2030. And as such, there's a lot of energy and interest in trying to get a handle on what is perceived as runaway costs in oncology.

But I would say there are a couple of reasons why VBC efforts have been thorny in oncology to date. One is that yes, drugs comprise the largest share of cancer treatment, costs a little less than half of the total, but the payer playbook to dealing with it often is simply utilization management strategies. So, formulary restrictions, step therapy, prior authorization, peer review, and that can be very frustrating for both patients and our providers. And while some of those restrictions are meant to standardize and reduce the variability in cancer drug prescribing, sometimes those can delay care and cause patient harm.

Another big problem that is related to the total cost of care is financial toxicity. It's a very huge problem in oncology, and this refers to the problems that a patient can encounter related to the cost of their treatment. So, studies have shown that patients with cancer are about two-and-a-half times more likely to declare bankruptcy than average Americans, more than a quarter of patients with cancer will deplete all of their life savings to cover the cost of care, and we found that almost a fifth, if not more, of patients with cancer who are on oral chemotherapy actually stopped their treatment due to cost.

Cost sharing, or having skin in the game, which was originally proposed as a way for patients to shop for care, I would say does not really make sense in cancer, and our unsustainable fee-for-service model, which strains the entire system, does not align incentives to keep costs down and all of that increases financial toxicity for patients.

I have read surveys of physicians, including a study that came out of my training institution, Memorial Sloan Kettering Cancer Center, which was led by my friend and colleague Emeline Aviki, shows that physicians do recognize that financial toxicity is a problem and they want to help their patients through it, but the reality is that many practicing physicians either are too busy with their clinical work, maybe they don't on a granular level understand what their patients are going through, and frankly, they don't actually have the tools at their disposal to tackle this at a root cause level.

I also further want to emphasize that pursuing value in oncology should involve more than just a focus on the drug spend, even though that is the big elephant in the room. There are other strategies that should be pursued. So, choosing a high value provider, enrolling in clinical trials, engaging early in palliative care—all of these require and deserve attention.

What I like about the Thyme Care model and the reason why I'm joining them as medical director is that by positioning themselves first as a navigation service for patients in their cancer journey, they uniquely take a whole person approach to value. I think if your starting point is grounded in the patient experience, and that is your northstar, then everything that you build on top of that will complement and inform that.

Thyme Care positions itself as a value-based enablement company. It can provide the support, services, and tech that practices would need to succeed in alternative payment arrangements. But even short of a full-risk sharing contract, I would say Thyme Care services are a very useful adjunct to patients and to the physicians that care for them.

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