Matthew is an associate editor of The American Journal of Managed Care® (AJMC®). He has been working on AJMC® since 2019 after receiving his Bachelor's degree at Rutgers University–New Brunswick in journalism and economics.
Coverage of the first half of the Institute for Value-Based Medicine® (IVBM®) session held September 19, 2019, in Philadelphia, Pennsylvania. IVBM® is an initiative of The American Journal of Managed Care®.
As he started the meeting with several leaders of Philadelphia-area cancer care, moderator Lawrence N. Shulman, MD, FACP, FASCO, deputy director for clinical services at the Abramson Cancer Center of the University of Pennsylvania, highlighted the central quandary of the US system:
“In cancer, our outcomes in this country are not as good as they are in other places,” he said, in opening the session of the Institute of Value-Based Medicine®. “In spite of the fact that we’re spending huge amounts of money, somehow our patients aren’t doing quite as well, and I think that is a very disturbing finding.”
Getting better outcomes—without spending more—will mean doing things differently. To discuss this, Shulman turned to Richard Snyder, MD, executive vice president of Facilitated Health Networks and chief medical officer of Independence Blue Cross, and Justin E. Bekelman, MD, director of the Penn Center for Cancer Care Innovation at the Abramson Cancer Center.
Payer Perspectives on Advancing Value-Based Care Agreements
Focusing on the high healthcare prices in Philadelphia and other metropolitan areas, Snyder discussed the impact these costs have in keeping and attracting business. “For many P&Ls (Profit and Loss), the second line item behind labor is healthcare cost,” said Snyder. Currently, US healthcare spending per capita accounts for 18% of the nation’s gross domestic product, which Snyder says is dangerously close to 20%, and a line the country cannot cross.
The transition from fully insured to self-funded healthcare for employers is an issue that arises as companies grow. Snyder stressed that when healthcare claims cause reinsurance costs to become more than a business can bear, funding for healthcare becomes derailed. When patients experience cost shifting, and a lack of cost transparency, it can cause them to delay treatments and preventive care, even though this can lead to an increase in treatment costs in the future. The rise in copays and member out-of-pocket costs occurs with high deductible plans. For many patients, high out-of-pocket costs and a lack of healthcare knowledge contribute to healthcare-related bankruptcy.
To address this public’s limited knowledge of healthcare, quality information is vital so the public can make more informed decisions. Snyder emphasized the need to publish more information about the quality of care, even though this process that has been met with lawsuits from medical centers claiming defamation. “How many people ask their physician: How many cases do you treat and what are your outcomes? Patients are scared to do that, they’re fearful it will insult the physician, even when it is their life,” said Snyder.
Inviting patients to discuss treatment options for their condition and providing them with ample information to make good decisions is a process that is expanding. In Pennsylvania, some hospitals are recognized as Blue Distinction Centers, which means they are recognized for their expertise in delivering specialty care. Snyder says that these newer models can assist in ameliorating costly treatments by prioritizing the concept of value-based contracting. Experience of care for patients is a variable Snyder said is growing in importance. Heightened accountability toward physicians and medical centers is being achieved through tools such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.
In lowering costs and improving care, Snyder described the concept of Engage, Enable, and Empower, which can be used to shift the focus toward patients. Engage, which focuses on the contract and the total value of care, promotes the responsibility of the health system to work with physicians for at least 1 year to take better care of insured patients. These contracts promote value-based care through tools like HCAHPS, and quality targets that would promote a 50:50 share for surpassing it and a 50:50 loss for missing it.
Enable is the process of gathering information and exchanging data for analytical processing. The expanded data exchange would include variables such as electronic medical record (EMR) extract, claims, lab results, and ADT messages in their databases, while additionally including opportunity analyses for analytics-based monitoring and reporting. Empower, which Snyder describes as the most powerful step, would then increase care delivery options for patients by using the obtained information to increase opportunities for innovative services such as telehealth to manage post-acute care and home care.
“This concept of doing everything the way we’ve always done and getting a different outcome just doesn’t work, we got to change the way we think, we got to break the old mold and build anew if we ever hope to get out of the mess that we’ve found ourselves in this country, ” said Snyder.
Advancing Cancer Care Innovation Through Value-Based Care
As he opened his discussion, Bekelman emphasized that regardless of the discernible innovations in cancer care, it continues to be suboptimal. “I would argue that we are at a turning point in cancer care today. We’ve made major strides improving survival, quality of life, but cancer care remains a multispecialty, multi-setting, fragmented specialty with huge administrative complexity,” he said. In the United States, Bekelman said, suboptimal care is attributed to one-third of the $3 trillion spent on healthcare every year.
Providing an example of 1 patient who had an unsatisfactory experience, Bekelman described a myriad of contributing factors that led to this level of suboptimal care. As the patient was diagnosed with prostate cancer, he had to undergo more than 8 weeks of both chemotherapy and hormone therapy at the facility, and at home due to the demands of his occupation as a truck driver.
Since the local care provider for the patient was separate from the healthcare system in which Bekelman worked, it impaired the management of the patient’s care. Several urgent care visits, and a nearby emergency department (ED) visit, was attributed to complications from his condition and the hormone therapy’s effect on his diabetes. The distress placed on the patient and his family was “totally avoidable,” said Bekelman.
Improvement through heightened glucose management from hormone therapy, and evidence that now points to 5.5 weeks of treatment as equal in effectiveness to 8.5 weeks, served as invaluable for Bekelman. “This gentleman’s experience was formative for me. As we confront this turning point in cancer care today, we need to challenge where we are,” said Bekelman.
To confront suboptimal care, Bekelman suggested that the goal should be to aim for a multispecialty cancer care that is accountable for the total cost. Bekelman provided 5 elements of risk sharing, bundled care, or effective capitation for cancer care to achieve this goal:
“Working as a team triggers a reorientation of how we work together,” said Bekelman. By collaborating as a team, as opposed to separate departments, Bekelman stresses that consistent expectations will be set for each specialized care physician. Furthermore, the incorporation of allied health professionals, nurses, and non-licensed coordinators will heighten efficiency in the pursuit of value-based targets.
Once team-based care is in place, Bekelman highlights the need to partner with generalists to ensure that comprehensive care does not get overlooked. “If we think back to this gentleman with diabetes, in the world of silo care, he falls through the cracks. In the world of multi-specialty accountable care for cancer, the ideal world, he’s taken care of,” said Bekelman. By essentially becoming the general contractor for patients with cancer, Bekelman says it allows providers to manage total costs. This process of risk sharing will achieve a sought-after care model for payers and patients, noted Bekelman.
Tying payments to quality and outcomes is an issue that Bekelman describes as both a challenge and an opportunity. Starting off with a limited set of measurements and expanding upon them was recommended in the discussion, with patient experience serving as the primary factor. Press Ganey, a healthcare performance analytics provider, was highlighted for increased use as this rating system would motivate physicians to improve care through details provided by patients.
Adjusting for risk is an additional challenge. While most oncologists may be put off by bundled payments due to variations in assigned patient health, Bekelman suggests incorporating this practice onto patients with diseases who do not need much risk adjustment, such as early stage breast cancer patients. Bekelman concedes that this cannot be done instantly, even if he desired to, but in utilizing a staged approach, adjusting for risk will grow in healthcare.
For the last element, pricing in lean healthcare in appropriate margins can be achieved through increased provider knowledge of costs, indicates Bekelman. “We have to understand [costs] to understand, how does the ask from the payer side comport with how we make margin,” said Bekelman. By understanding costs at main hospitals, and community-based practices, providers can assist in steering patients to cost-effective treatment.
Once these costs are known, it delineates value of care through pricing in the appropriate margin. “Those providers that get ahead of this and provide a true value equation to insurers or employers, those are the ones who end up being the market leader,” said Bekelman.