“Quest for Value: Advancing Oncology Value-based Care,” this year’s first installment in the Institute for Value-Based Medicine (IVBM) from The American Journal of Managed Care®, zeroed in seniors, a population that’s growing not just in Florida but across the United States. Older Americans are more likely to develop cancer, but thanks to better detection and treatment, they are more likely to survive cancer, too.
The elbow bumps shared at the Tampa Hilton Downtown on March 5, 2020, foreshadowed what was to come: this would be the last large gathering for a while at which oncologists from across Florida Cancers Specialists (FCS) would be able to join with physicians and other stakeholders for a strategy session on what this group does best: bringing value to cancer care.
“Quest for Value: Advancing Oncology Value-based Care,” this year’s first installment in the Institute for Value-Based Medicine (IVBM) from The American Journal of Managed Care®, zeroed in seniors, a population that’s growing not just in Florida but across the United States. US Census Data show that by 2030, about 1 in 5 Americans will be 65 years or older.1 Older Americans are more likely to develop cancer, but thanks to better detection and treatment, they are more likely to survive cancer, too.
If everyone has a better than 1 in 3 chance of developing cancer in their lifetime,2 then care for a senior with cancer is a shared responsibility. There’s an oncologist and the primary care physician. There’s the payer who enrolls the person in health plan, and there’s the pharmacy that may see the patient the most—not just for prescriptions, but also for supplies, personal products, or a routine question.
All were represented at the Tampa event, which featured:
• Lucio Gordan, MD, president and managing physician, FCS
• Sam Asgarian, MD, former head of Clinical Health Products and Services, CVS Health
• Ray Parzik, director of Network Programs, Florida Blue
• Jeff rey Lowenkron, MD, MPP, chief medical officer, The Villages Health
• Michael Diaz, MD, assistant managing physician, FCS; president, Community Oncology Alliance
• Maen Hussein, MD, physician director of finance, FCS
Gordan opened the discussion by introducing the classic defi nition of value: quality divided by cost. But he explained that value can be subjective, because, “It depends on who the stakeholder might be.”
When one thinks of “value” like a pie, and the slices must be shared among the physician, the payer, the pharmaceutical company, and the pharmacy benefi t manager (PBM), then “it gets very tricky,” he said.
FCS is among the leading practices in the nation fi guring out how to navigate this new territory in oncology care, as it has been working with value-based payment even before CMS’ Oncology Care Model (OCM) existed. Making value-based reimbursement work requires collaboration with others in the healthcare landscape who interact with the patient, so that information is shared.
Learning how to enhance provider-to-provider communication creates “a new culture of sustainability,” Gordan said.
Top Down Commitment
So, how did Florida Blue get to the point of collaborating with FCS on its Community Oncology Model? Parzik shared the timeline for the process and struck a theme heard often at IVBM sessions: without leadership from the top, the shift to value-based care does not happen.
“It takes top down commitment,” Parzik said, describing the process that began in 2010 with a pathways program and evolved from there, including an intense 6-month period of program development that emerged when a community oncology practice, a large hospital system, and a large health plan decided to make the leap.
But bringing all the parties together—to get the technology and the electronic health records to interact—mattered. Within a few years, Florida Blue had set up an accountable care organization. That mattered as the plan prepared for the arrival of the Affordable Care Act (ACA). “Florida Blue was in all 67 counties when the ACA
went live, and we’re still successful,” Parzik said.
But what led the payer to do an oncology-based model? “It’s the most difficult thing to try to measure,” he said. Cancer has diff erent stages, patients have diff erent genetics, and administrative claims data don’t reveal all that. “How do you marry clinical analytics with fi nancial analytics?”
Hence the other truism of value-based care: the physicians must buy in.
The current collaboration with FCS dates back to 2015-2016, when Florida Blue saw opportunities to work with the practice to run pilots and refi ne attribution models before they were used on larger groups. Getting it right is important, Parzik said.
What indicators are the most helpful?
“If this is a shared savings model, we don’t want to have any fi nancial transaction take place at the detriment of quality. … We¨want to save money [through] care coordination.”
There’s a big diff erence today from the first generation of managed care, he said. Payers have learned that squeezing the provider to the point that the provider cannot succeed makes no sense. “If people are not succeeding, it’s not sustainable,” he said.
Value-Based Decisions on Therapy
Asgarian presented details of the Novologix platform, which CVS Health developed to act as a built-in “second opinion” to deploy value-based contracting and speed prior authorization of cancer therapies.
“Why did we start with oncology?” he asked rhetorically. “There¨is great differentiation compared to what else is out there.”
Things like the National Comprehensive Cancer Network (NCCN) guidelines act as a built-in check against prescribers going astray, and the top-tier providers in each area of cancer are well known. So, Asgarian said, the idea was to take Novologix which was created as a drug platform, and turn it into a treatment decision support platform.
By integrating the platform with NCCN guidelines, genetic information, and information from care managers, and guideline customization, Asgarian said, the goal is to “not just treat the cancer but treat the individual.”
Where the Seniors Keep Coming
With 130,000 people, The Villages is the size of a city. It has 3 town squares, thousands of social clubs, music every night, and “more baseball games than Major League Baseball,” according to Lowenkron, the person tasked with keeping them all healthy.
Living up to the moniker, “America’s Healthiest Hometown,” is no small order, but The Villages Health embraces it uniquely. In a place where the average age is 70, there are 100,000 people eligible for Medicare, so it makes sense for CMS to work with Lowenkron to get it right.
If people wonder why care is fragmented, he said, historically Medicare would not pay for an extended visit in which various specialists would come to the patient. But if the patient made separate, 15-minute appointments, “they pay everybody!”
Gone are the days when a person got sick and went “to the airport,” he said. The Villages now has multiple care sites, anchored by its own hospital and a 285,000 square foot, 5-story ambulatory health center, hotel, and spa complex. Specialty offi ces for oncology and ophthalmology are on site, and family members can stay nearby. Lowenkron said The Villages is very careful to evaluate which services it will provide and which ones are already available in the area, so it does not create more supply in the market than can be naturally absorbed. Careful collaboration with FCS and other providers ensures the right amount of care.
By taking these steps, “Our ER use is relatively low,” Lowenkron said.
Where Things Could Improve
Hussein and Diaz joined the panel discussion that followed, where talk turned to the need for primary and oncology care to do a better job of coordinating on advanced care directives. “It’s an incredible challenge,” Lowendron said. He admitted that even though seniors have thought about it “84% of the time,” primary care doctors don’t ask often enough.
“Only one group is worse. We are among you all today,” he said. Diaz addressed rising drug costs and how they aff ect the senior population—as well as oncology practices as they take on risk. Stop loss is handled so that no one individual physician or office absorbs an outlier, which is better for patient and provider alike. Hussein, wearing his finance hat, said The Villages and FCS treat many of the same patients, and have “reached a middle ground to share incentives.”
Other topics included the future of PBMs in the era of vertical integration: would they survive, and if so, how many? Were they even necessary?
Diaz, in his role with COA, discussed the future of OCM 2.0, an alternative payment model the group developed as a diff erent way to reimburse practices for drugs, which has been a chief source of complaints about the CMS model—Gordan has published research showing that practices are being shortchanged under the current system.
Parzik addressed the topic of site parity—also a key issue for community oncologists, who say that reimbursement structures favor hospitals at their expense, even though they deliver care more effi ciently. Hospitals, Parzik said, “always carry leverage,” due to their impact on the community. “How do you fix that?”
He called for “creating preferred partnerships, with structured benefits with your membership.” As prices become more transparent, the cost-saving sites will gain. He sounded much like a consumer when he said, “It’s very difficult to shop for healthcare.”
Payers prefer discounts backed by evidence—competitive intelligence—that they have an actual impact on care.
“There’s a whole host of models in the delivery system that are somewhat perverse,” Lowenkron said. “I can never explain why they should be that way. … “No one is going to raise their hand and say, ‘I think I’m a little overpaid.’”References
1. Colby SL, Ortman JM. Projections of the size and composition of the US population: 2014 to
2060. Current Population Reports, P25-1143, US Census Bureau, Washington, DC, 2014.
2. Siegel RL, Miller KD, Ahmedin J. Cancer statistics 2019. CA: A cancer journal for clinicians.