Investment in Value-Based Specialty Care Pivots on Site of Service, Understanding Areas of Risk

Even before sampling the flights of bourbon, guests who arrived at the Omni Nashville Hotel on May 11 sensed this Institute for Value-Based Medicine (IVBM) meeting would be an evening of celebration. Just 3 weeks prior, host network OneOncology had announced its upcoming acquisition by TPG and AmerisourceBergen, in a deal valued at $2.1 billion that will allow the specialty network’s physicians and practices to retain an ownership stake.¹

Co-host Chris Booker, a partner at Frist Cressey Ventures, which was an early investor in OneOncology, shared the good mood as he took the stage with OneOncology’s Duncan Allen, MHA, who serves as senior vice president for clinical services. Booker and Allen outlined an evening strikingly different from earlier IVBM sessions: instead of focusing only on how value-based care is shaping oncology, speakers would be examining trends in value-based care more broadly, as they cut across specialty care, from nephrology to oncology navigation to gastrointestinal care.

And between speakers, guests would learn about bourbon. Yes, really.

Why specialty care? For starters, that is where the money is—or at least a lot of it. Allen discussed data from a 2020 JAMA article that showed prescription drug spending in specialty care accounted for about $1 trillion. “That blew me away when I saw that,” Allen said. Such spending represents a 29% growth in prescription drugs overall and 18% in specialty care between 2002 and 2016.²

Thus, as Booker would explain later during a panel discussion, although many have invested in primary care—with good reason—figuring out how to tame the beasts of specialty care could work wonders in controlling costs and improving quality.

As Allen noted, “addressable issues” vary by specialty. “For oncology, drug is king,” he said. But in nephrology, site of care drives costs. In obstetrics or orthopedics, creating standardization holds the key to better care and savings.

Coming out of the pandemic, a hot topic today is access, he said. Practices learned that telehealth could solve longstanding issues with in-home care and rural delivery, and now entrepreneurs are rising to respond. “The biggest thing that is driving current day trends is really more on the call side, where we have site of care. And I think I’ve heard more people say ‘site of care’ in 2023 than I have in the prior 10 years,” he said. “And we have a number of policy pressures around drug pricing, which those of us in the oncology space have [become] way too familiar with.”

The need for community oncology practices to collaborate as CMS pursues payment models that some fear will become mandatory helped drive interest in the OneOncology transaction.³ In 2022, the total volume of specialty practice transactions reached $22 billion, although that is expected to cool off to $15 billion in 2023. Venture capital and private equity firms account for 70% of the transactions, according to data that Allen and Booker cited from Silicon Valley Bank’s 2022 annual report on health care industry trends.⁴

Value-based care remains challenging, Booker said, because it still means different things to different people. Frist Cressey has seen successes but also passed on companies that later proved to be winners, he said. Booker said not every company or practice he meets with has the same concept of risk.

“You can go fee-for-service with a little bit of a kicker, all the way to full capitated risk,” he said. As companies make this transition, full risk is not the right business model in most cases, he added.

Private investment will continue, as partners look for opportunities to support lower-cost models of virtual or in-home care. Specialty practices that succeed will be those that understand how to reduce the costs of units of care, measure quality, and coordinate care with data, so that services are targeted based on clinical segmentation.

There is never a perfect time to try value-based care, however.

“So many times in health care, we look at all the problems out there, wishing there was something that somebody could change,” Booker said. Instead, he advised, we should focus on what the “late philosopher” and Tennessee whiskey maker Jack Daniels said: “Don’t waste your time wishing for things you don’t have. Do your best with what you do have.”

Taking on Risk for Kidney Care, Chronic Care Management

When he worked as an emergency deparment physician, Amal Agarwal, DO, MBA, recalled his frustration at seeing the same patients over and over again. “I really did not feel like I was making a difference,” said Agarwal, who decided to join Humana to work on the “upstream” problems that could improve patients’ lives. Here, he learned about Monogram Health.

Today, as Monogram’s chief clinical officer, Agarwal has gone a step further, as the company now assumes risk for patients with polychronic conditions, most notably chronic kidney disease, one of the most expensive and debilitating conditions to treat. It is also one linked to poverty and poor quality of life.⁵

Monogram is now responsible for more than 66,000 patients in 34 states, and it is getting results with an in-home model that Agarwal described as less hierarchical and more likely to address the social determinants of health that affect good outcomes.⁶ The first contact often occurs when a patient is hospitalized, when they are most likely to be receptive to the service. Then every patient gets a complete initial exam in the home, which can be quite revealing.

“We review the prescriptions, and we also review the actual medications, including the ones in the fridge. You’ll be surprised how many times that insulin is not mentioned. You’d be surprised how many times you find medications that are expired or [have] maybe [been] given from a neighbor,” Agarwal said.

That home visit covers health care goals and provides insight into each patient’s barriers to success. Questions that can be hard to ask in an office—such as whether someone has enough to eat—are more readily addressed if the refrigerator is empty.

Monogram’s mission, Agrawal said, is to take on complex case management, to identify the care “gaps” that are being missed, and close them in partnership with community physicians.

“Population health has to be data driven,” he said. “I think the secret sauce that we’re doing right now is we [are] taking evidence-based outcomes, and we’re putting value to it in terms of days that a patient can be at home, and [giving] it an economic value.”

Sharing these metrics with care teams allows everyone to be part of driving that value, and it sets Monogram up to have strong relationships with payers. Under the model, Monogram assumes risk for an attributed population, not just those who are “engaged” in their care, Agrawal said.

Monogram’s team-based approach is key, Agarwal noted. A “pod” structure creates a team responsible for 5000 attributed members, of whom an estimated 35% are engaged. “Working in a team environment, you’re going to get much better outcomes,” he said. “I try to instill [the view] that nobody is alone here. We have pharmacists; we have social workers; we have nurses…. Don’t ever feel like you have to make the decision by yourself. And we enable population health through a robust analytic platform, which helps us take on the full risk.”

The company works with specialists who may offer a “curbside consult” with local doctors, making it clear that the service is about sharing in the patient’s care. “We’re not trying to isolate the community doctors,” he said. “Once we’re able to get in front of the community doctors and they realize what we’re doing, they realize we’re not actually trying to get in their way.”

Monogram has moved beyond just achieving savings. As of April 2023, the company reports a 19% rate of at-home dialysis starts, compared with 13.3% nationwide. Agrawal notes that US rates for at-home dialysis remain woefully behind other countries—Canada is at 26%, Mexico at 32%, and Hong Kong at 80%. “Right away, that tells you it’s not a technology issue, it’s something else,” he said.

For CMS, shifting Medicare patients to at-home dialysis is a key strategy to control costs and improve quality of life as the number of patients with end-stage renal disease is expected to grow.⁷ But Monogram also takes charge of managing the patient’s comorbidities, so that the need for dialysis is delayed or forestalled completely. Agarwal presented data to show that compared with national averages of patients with renal disease, patients under Monogram’s care have better rates of controlled glycated hemoglobin and hypertension, lower rates of hospital readmission within 30 days, and almost twice the rate of engagement between primary care physicians and nephrologists.

“In the end, we’re really trying to transform the patient experience,” Agrawal said. “We’ve combined the managed service benefits with a diagnose-and-treat model. But we’re also trying to do it at the patient’s home.”

Improving Patients’ Lives With Better GI Care

As a group, patients with gastrointestinal (GI) conditions often suffer quietly. Their diseases, such as Crohn or irritable bowel syndrome (IBS), are painful and hard to diagnose, and the resulting stigma means many will not discuss what is wrong with friends or coworkers. GI specialists are in short supply, which can mean a wait of 3 months to see one, and many patients land in the ED with severe stomach pain or constipation before they get an appointment.

“People with IBS report worse quality of life than people on dialysis,” said Sam Holliday, MBA, CEO of Oshi Health, which seeks to deliver better GI care. These patients, he said, “would give up 15 years of their life if you could solve it today.”

Holliday’s company is trying to do just that, and in the process reduce the cost of care that now totals $15,189 per patient or $136 billion a year in the United States; patients who have GI-related conditions spend $26,294 on all health-related costs per year on average.⁸ It is a huge issue for employers—beyond the costs, GI-related conditions are a major cause for absenteeism.

Yet these conditions can be hard to track; symptoms for many are similar and may be recorded in an electronic health record as other things. And changing the way care is delivered is not easy, Holliday reports. GI specialists are in demand and well compensated—new fellows can make up to $600,000 a year—so there is little incentive for them to change the current fee-for-service dynamic, which focuses on lots of procedures.

But Holliday, whose mother and sister have GI issues, believes patients deserve better, and Oshi seeks to use technology to serve them better. Oshi’s arrival on the scene—at a time of cuts to GI practice reimbursement and rising personnel pressures—may be well timed for change.

Payers are seeking to rein in costs, as GI-related conditions rise on their radar. “And unfortunately, with all that spend, the experience of the patient is not great,” Holliday said. Patients wait months for a very short appointment and may be told what they do not have, but may leave thinking “it’s all in their head.”

Recent evidence shows that a more multidisciplinary, medical home model that incorporates dietitians and behavioral health professionals into the team offers better value.^9,10 This is the approach that Oshi Health takes, as it uses a series of virtual appointments, clustered over 2 to 3 weeks, to understand what is triggering a patient’s symptoms. “Then we will get a solution that works for that individual,” Holliday said. “Trying to do that in a brick-and-mortar model is not possible,” if patients have chronic symptoms that make them afraid to leave the house.

Although a gastroenterologist leads the team, nurse practitioners and physician assistants working at the top of their licenses, and following care protocols, guide most of the visits. “It really unlocks the supply-demand mismatch,” Holliday said, and it puts more focus on behavioral health.

“We’re not trying to rebuild what the current system does well,” he said, but having a care coordinator on team helps patients navigate prior authorization when procedures are needed. In a peer-reviewed study, patients reported 98% satisfaction with the experience. Many said they felt listened to for the first time.¹¹

Said Holliday, “We’ve had many of our patients say we gave them their life back by solving the symptoms.”

Reducing Fragmentation in Cancer Care

At first, Thyme Care appears to offer virtual cancer care navigation, offering practices the option of just-in-time delivery and the ability to share staff. And that would be a cost-effective way to provide this key service, which became more challenging to offer now that many practice that once took part in the Oncology Care Model (OCM) are no longer receiving monthly payments to help cover these costs.¹²

But as Samyukta Mullangi, MD, MBA, incoming medical director at Thyme Care explained, the technology and team at the Nashville-based population health provider offer much more than that. Mullangi, who is concluding an oncology fellowship at Memorial Sloan Kettering Cancer Center, explained how Thyme Care offers 3 things at once: oncology-focused population management, partnerships with both payers and risk-based entities to drive better outcomes, and a patient-centered virtual navigation team, which is organized geographically to develop market-level expertise.

This design allows Thyme Care to address some of the biggest challenges in cancer care delivery, she said. Cancer is heterogeneous, and the tremendous diversity in both cancer and treatment types—governed by clinical guidelines—can seem at odds with the call for value-based care, which seeks to squeeze “outliers” from the system. Even when delivered appropriately, cancer care is expensive, and thus a target for insurers.

“The [National Cancer Institute] estimates that the direct financial burden that is borne by patients is $20 billion—that is 10% of the actual total spend on cancer,” she said. “Fifty percent or more of cancer patients take on some degree of debt in dealing with their disease.”

Some of this burden happens because patients do not understand their symptoms and care is fragmented, so they end up in the hospital unnecessarily. These are the costs that Thyme Care hopes to trim from the process—for the betterment of all—with its virtual support system.

How does it work? Thyme Care creates shared savings arrangements with payers, but its real genius is deep relationships with providers, so there is a rich understanding of what is happening with patients. As Mullangi explained, the more data Thyme Care develops, the more it knows about which practices offer good care, which it can share with payers and primary care providers that make referrals.

“We want to be able to navigate the patient to a more high-value cancer clinic,” Mullangi said. “This is the type of data that we share with our partners.”

Primary care practices would want to know that “this is where the leakage is happening,” she said.

The focus on engagement can improve so much. It can address gaps in care due to social determinants of health, spending due to acute care utilization, and the failure to use hospice. Mullangi sees the need for Thyme Care increasing as practices look for ways to meet requirements of the Enhancing Oncology Model, which starts July 1.¹²

Even in the early stages, Thyme Care was able to demonstrate savings of $429 per patient, which it presented at the American Society of Clinical Oncology (ASCO) Quality Care Symposium in 2022.¹³ Since that time, Mullangi said, new workflows have improved processes around palliative care and the referral process. “So I anticipate that when we repeat this analysis, this number will only grow.”

Using Data to Make Better Care Choices

How do you pick a doctor?

According to Daniel Stein, MD, MBA, founder and CEO of Embold Health, if you are like most people, you might get a recommendation from a friend or colleague. You might look up the doctor on Google and read an online review.

Stein showed an example of a pair of seemingly similar obstetricians, except the online review did not reveal that one had a far higher rate of performing episiotomies, a painful incision in the perineum that has not been the standard of care for 30 years. How would an expectant mother learn this when looking for a physician? How would any patient, for that matter, learn if a doctor performs high rates of procedures that are outside clinical guidelines?

Enter Embold Health, which seeks to research the rates of clinical measures that providers are actually performing and report them to its clients. These are mostly large, self-insured employers with the ability to work with payers to decide which physicians will be part of their networks.

Embold Health has a database that covers 160 million lives. It reports down to the physician level—not the health system level—because of evidence that when it comes to following guidelines, there is great variation within health systems. In addition to tracking this information, Embold Health also reports on effectiveness of care.

“The key question here is, are you getting good outcomes?” Stein said.

In making these assessments, Embold Health strives to be fair. Not every patient is the same, and evaluations take note of differences in patient populations, Stein noted. Doctors with worse outcomes will say their patients are sicker, and in some cases it is true. “It’s important to adjust for the patient factors, for social determinants of health—you don’t want to punish doctors for caring for disadvantaged populations,” Stein said. “Some places really do more complex care.”

Embold Health also examines total cost of care, especially in common procedures such as knee replacements. And the company is always on the lookout for cases where surgeons are performing unnecessary care that does not help the patient. For example, he mentioned that data from clinical trials have shown that one common procedure, arthroscopy, offers no relief for patients with knee osteoarthritis.¹⁴ Yet many patients still receive it, Stein said.

The rating process translates into better care and reduced costs. Embold’s data show that patients who went to higher-rated physicians had a 22% reduction in potentially unnecessary care, with annual per member reductions in spine surgery and care (45%), gastroenterology (31%), other orthopedic/joint care (23%), obstetrics (18%), and gynecology (16%).

This process is not easy for physicians, he said. Many are competitive and do not like being told they are wrong. Stein said the process is not about hurting doctors but aims to help them make changes to reduce unnecessary care.

“I honestly believe that most providers that are delivering unnecessary and inappropriate care are not doing it because they’re bad actors,” Stein said. “By and large, clinical practice guidelines and the science have changed. And doctors just tend to be pretty stuck in the way they practice. So a big part of our mission at Embold is to get this information in the hands of the providers to help them do something differently.

“We’ll share the data with any doctor, any provider, any health system, to help them understand how they perform.”

“The Oracle of OneOncology”

According to his colleagues, Garrett Young’s title, senior director of clinical and strategic analytics, does not fully describe his role at OneOncology. Allen noted that Young is called “the oracle of OneOncology” for his role in making analytics actionable, a core ingredient in the network’s ability to help practices large and small improve care delivery.

He started with a pair of equations––“Data + Context = Information,” and “Information + Action = Outcomes”––and then explained that using data starts with understanding what questions they can and cannot answer. Getting to “small” data when possible is important, and so is meeting end users where they are. For all the talk of “big data,” Young said, “we’ve learned that data [have] to be really small and specific and actionable if you want somebody to actually take [them] and do something with [them] as part of their day-to-day work.”

Young repeated concerns shared by others. Much of the cost in oncology involves therapy; in many cases, physicians can choose between similarly priced chemotherapy options or brand-new treatments that represent a new standard of care. Although inpatient utilization and ancillary services can be managed, “those are generally a drop in the bucket when we look at overall oncology spend,” he said.

As CMS prepares to launch the Enhancing Oncology Model, practices face major challenges with managing risk, given the need to stay within National Comprehensive Cancer Network clinical guidelines. Within OneOncology, “a lot of our practices are starting to leverage tools that let us track and identify physician outliers who may not be following guidelines at the same rate that others are,” Young said. “So we’re starting to have the ability to measure that.”

However, Young pointed out, compared with other specialties, it is challenging for oncology to find the right metrics and make information actionable. Some keys that Young has identified include the following:

Actionable information and self-serve tools must be at the point of care.
Physicians respond to data that show them how they rank relative to their colleagues.
Many measures rely on changing physician behavior—and physicians are busy people. Practices that succeed must find communication methods that drive change.
Tools for nonphysicians must mesh with workflows and set them up for success, whether it is a palliative care referral or completing a field on a chart that will be useful later on. Much thought must be given to these tools.

“Otherwise, we’re going to generate a report, and nothing is going to happen,” he noted.

He displayed versions of the dashboards and tools created to help staff at the practice level. However, Young said, there is no substitute for training people on the frontlines who make these systems work at the practice level.

It often comes down to identifying opportunities, acting on them, and then spreading the word. Young offered an example of choosing between 2 drugs for patients with bone issues: a commonly prescribed one costing $2500 versus an alternative costing $25. If switching is not happening, what is the reason?

“This is one of those great opportunities,” Young said. “How do we get that information into their hands so they can do something about it?”

References

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Clinical trial results demonstrate Oshi Health’s multidisciplinary GI care improves patient outcomes with savings greater than $10,000 per patient within six months. News release. Oshi Health. January 31, 2023. Accessed May 29, 2023. https://bit.ly/3qdGfuG
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