As rising drug costs continue to take up a larger portion of the total cost of care, practices in the Oncology Care Model find themselves in control of a shrinking portion of total costs, according to anecdotes from an academic medical center and a community-based practice during the National Comprehensive Cancer Network’s Policy Summit held September 12 in Washington, DC.
Three years into the Oncology Care Model (OCM) and with feedback now from 4 performance periods, practices participating in the value-based model continue to strive for successful practice transformation that drives appropriate utilization and contains costs while keeping the patient and oncologist at the forefront.
However, as rising drug costs continue to take up a larger portion of the total cost of care, practices find themselves in control of a smaller portion of costs, according to anecdotes from an academic medical center and a community-based practice during the National Comprehensive Cancer Network’s (NCCN’s) Policy Summit held September 12 in Washington, DC.
In the last decade, there has been a more than 5-fold increase in incremental anticancer drug costs; average annual costs rose from $30,000 in 2006 to $161,000 in 2015. However, there has not been a corresponding increase in the measure of efficacy, according to scores from both the American Society of Clinical Oncology and the European Society of Medical Oncology,1 explained Kerin Adelson, MD, associate professor, chief quality officer, and deputy chief medical officer for Smillow Cancer Hospital at Yale New Haven/Yale Cancer Center.
Despite the challenge, approximately one-third of practices have been able to lower their total costs and achieve savings under the OCM. Adelson and Diana Verrilli, MS, senior vice president of Strategy and Practice Solutions at McKesson Specialty Health, which is part of the US Oncology Network, shared their experiences the model and what they’ve learned since they entered.
Addressing What You Can
Comparing costs of care from 2012 through 2015—before the OCM was implemented—with performance periods 1 through 3, overall cost of care increased from $28,000 to over $32,000 for Smilow Cancer Hospital; however, this was less than what CMS expected, so the network was able to achieve savings. To date, it has received over $6 million in performance-based payments.
Looking within the total cost of care, spending significantly increased for drugs, which accounted for 53% of costs between 2012 and 2015 and jumped to 60% in performance period 3. However, by focusing on the remaining 40% of other healthcare costs, Smilow Cancer Hospital was able to exert tighter control. The hospital did this by honing in on utilization patterns, specifically in the emergency department, with inpatient care, and in postacute care use. Through a new revenue stream under OCM, Smilow Cancer Hospital implemented infrastructure focused on those areas, by building a care management program, increasing access to palliative care, and opening an urgent care center.
The US Oncology Network has also seen success with the model. With 15 practices participating in the OCM, 14 fell below the benchmark during performance period 4; 5 practices received performance-based payments. Together, the practices achieved $36 million in Medicare savings, totaling $89 million in savings over 2-year period, explained Verrilli.
While most of the network's efforts also largely focused on reducing utilization, practices were able to target certain areas where they noticed large variation in utilization, including supportive care drugs. Looking at pegfilgrastim, for example, the group implemented appropriate use policies, which yielded positive results and brought the practices closer in line to, and even below, other OCM practices’ utilization rates.
Changing and Standardizing the Way Doctors Practice
“Never underestimate how long it takes to change physician behavior and maintain that level of change,” said Verrilli.
It’s one thing to build supports around the oncologist, but it’s much harder to change the way doctors practice, added Adelson. “There’s a black box around what goes on between a doctor and a patient in an exam room,” she said.
So, Smilow Cancer Hospital tried to uncover how their doctors were practicing things like goals of care discussions, which drives earlier use of hospice, as well as their communication skills and their patterns of practice.
The most important piece of driving new behaviors, and reinforcing good ones, is through data, said Adelson. Working with Flatiron, Smilow Cancer Hospital implemented an end-of-life dashboard that every 4 months sends doctors data reflecting their care practices for their patients who died.
Within the data is what percentage of those patients got cytotoxic chemotherapy, what percentage got oral therapy, and what percentage got immunotherapy. The doctors are also able to see their cost measures, including where they landed compared with other doctors as a whole, by cancer type, and by drug use.
“We can then get a conversation going about which drugs to use and when in order to drive more appropriate behavior,” said Adelson, who emphasized the importance of drilling down to the patient level and providing doctors with individual anecdotes.
Verrilli echoed Adelson, saying “starting the OCM has led to a significant paradigm shift in how care is provided.”
She explained that her group also placed an emphasis on sharing data with their doctors quarterly and giving them goals of where there utilization rates should be.
Behavior change also came from embracing clinical pathways at the point of care through a partnership with NCCN. For example, several oncologists in the network rarely see patients with pancreatic cancer, she said. By using value pathways implemented through the partnership, when an oncologist sees one of these patients, they’re equipped with the tools needed to treat them.
Recognizing the Challenges and Pain Points
Despite the success, the model does present its challenges for the 2 networks. In addition to the high cost of drugs, challenges faced by the networks include:
Saluja R, Arciero VS, Cheng S, et al. Examining trends in cost and clinical benefit of novel cancer drugs over time [published online March 30, 2018]. J Oncol Pract. doi:10.1200/JOP.17.00058.