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Making the Leap to Prospective Risk in Value-Based Oncology Care

Evidence-Based OncologyOctober 2018
Volume 24
Issue 11

The Institute for Value-Based Medicine travels to New York City to learn how technology and trust are key to making the leap to two-sided risk.

As physicians, including oncologists, gain comfort with payment for value, one question keeps popping up: What will it take to move from being rewarded for good results to accepting losses for bad ones?

The challenge in getting specialists to join the shift from 1-sided to 2-sided risk is the next big hurdle in healthcare transformation. In a Health Affairs blog post in August, CMS Administrator Seema Verma made it clear that Medicare ACOs will no longer be allowed to linger indefinitely in 1-sided, or “upside-only”, status.1 But oncologists say their situation is different. For years their compensation has been tied to the price of drugs in Medicare Part B, a system they didn’t invent.2 So far, the hurdles found in being fairly compensated when using expensive cutting-edge therapies under CMS’ Oncology Care Model (OCM) are very real.

Making this leap to 2-sided, or prospective, risk was the theme of “Future Perspectives on Oncology Value-Based Care,” a September 27, 2018, presentation of the Institute for Value-Based Medicine (IVBM) that took place at the Sofitel Hotel in New York City. Serving as moderator was Andrew Pecora, MD, FACP, CPE, chief innovation officer, professor, and vice president of Cancer Services at John Theurer Cancer Center, Hackensack Meridian Health. Joining Pecora were:

  • Lani Alison, BSN, MS-HCQ, PCMH, CCE, vice president of clinical affairs, Regional Cancer Care Associates, which has 30 locations in New Jersey, Connecticut and Maryland;
  • Luis Isola, MD, director of cancer clinical programs at Mount Sinai Health System, New York City;
  • Allen Karp, executive vice president of healthcare management and transformation for Horizon Blue Cross Blue Shield of New Jersey, which serves 3.8 million members.

Where the Money Is

As Pecora explained, there’s a simple reason why payers, including Medicare, are taking aim at the waste in healthcare spending: That’s where the money is. At $2.9 trillion a year in the United States, healthcare spending accounts for 17% of the US gross domestic product. When one considers estimates that 30% of this is wasted—on the order of $2.4 billion a day—that’s too much to not find ways to deliver higher-quality care more efficiently. Like each of the speakers, he said that spending money wisely starts with learning what isn’t working and then doing everything possible to minimize variation and maximize quality.

Pecora said looking backward at claims and outcomes to gain insights is hampered by billing codes that are overly broad and reveal too little about the specifics that affect outcomes, especially in cancer. Things like comorbidities, family history, genetic information—none of that is in the codes. Pecora then showed the attendees a picture of an apple with a grocery store bar code, which tracks where the apple was picked, its price, and where it was stored, as well as links to other databases. “When I saw this, it made me laugh,” he said. “There’s more information on the bar code of an apple than in your healthcare data.”

At Hackensack Meridian, the quest has been to figure out how to build a bar code for oncology. Pecora explained that “bar code” is the foundation for COTA, the technology company that brings together oncologists and data scientists to build actionable data, which allows clinicians to make better decisions based on outcomes seen in similar patients. Key information from bulky records and physician notes is pressed into a numeric code, called the COTA Nodal Address,3 or CNA. This becomes a precision medicine tool by folding in a patient’s diagnosis, genomic status, tumor type, and the type of diagnostic test used. Using this tool, Hackensack has partnered with Horizon to develop a bundled payment model in oncology, which received overwhelming approval from the Physician-Focused Payment Model Technical Advisory Committee.4

Pecora walked the audience through examples from breast cancer to show how the tool allowed the health system to work with Horizon to produce data that identified the best treatments for certain types of patients, as well as outliers. “Once it’s digitally mapped, it’s not that hard,” he explained. Yes, there are pathways for treating disease states but “not all diseases are the same. Not all patients are the same. Not all doctors treat the same disease the same way. And not all doctors treat the same disease the same way every time. The data show us this happens every day.”

Finding where this occurs uncovers those human behaviors that lead to variation, deviations from quality care, and higher costs. “We’re starting to think about this completely differently,” Pecora said. As Karp would emphasize later, payers and health systems would rather not use tools, like prior authorization, to manage spending. “No one wants patients to not get the care they should get,” Pecora said. “But can they do that and get care that’s not wasteful?”

Creating a Change in Culture

Identifying where waste and poor-quality care are happening is only the first step. Preventing them demands a change to the organization’s culture, which is what the OCM is designed to do, according to Alison. At its heart, she said, healthcare transformation is about developing a unified system of delivering care that ensures the integrity of the core processes, while finding efficiencies and lowering costs. Cancer care is constantly evolving, so transformation must do the same. “It is a journey, not a destination,” she said. The components of the OCM demand that every person in the organization must be on board, from the leadership to the surgeons to the nursing staff to the front desk clerk who is trained to work with a patient who has just been told she has stage IV breast cancer.

A key feature of Regional Cancer Care Associates’ (RCCA) implementation of the patient centered medical home is that it must be “payer agnostic,” which means its care delivery model meets all the requirements of the OCM or other alternative payment models for commercial payers, as well as various accountable care organizations (ACOs) and other collaborative agreements. She showed a table with various measures from OCM, the Merit-based Incentive Payment System, the Oncology Medical Home from the National Committee for Quality Assurance,5 and the Quality Oncology Practice Initiative from the American Society of Clinical Oncology.6 RCCA met them all. This is essential given RCCA’s footprint across 30 sites in 3 states. A single model of care “harmonizes not only the people of RCCA but promotes a common goal and objective of providing the highest and safest standardized care in the provision of oncology services outside the walls of the hospital,” according to information from Alison’s presentation.

As examples, Alison said she works with the staff on processes so that time with patients is not spent looking at the computer and updating the electronic health record. Because of the OCM’s focus on palliative care, “We have trained our staff to state the conversation about the end of life and what their wishes are,” Alison said. “It’s our duty as clinicians to honor their wishes.”

RCCA measures improvement with reductions in emergency department (ED) visits and readmissions, measurable improvements in patient experience, and increased bonus payments.

Consolidating the Data

Isola, from Mount Sinai, agreed that changing the culture starts with the faculty. “You need those faculty believing in the common mission,” he said. Developing clinical ways, determining standards of care, establishing patient conferences, operating tumor boards, integrating clinical trials, and weaving information technology (IT) throughout mean the faculty must “buy in” to healthcare transformation from top to bottom. The role of IT in consolidation data and creating a dashboard to measure progress is crucial. “Data can standardize your operations and support your practices, projecting what your cost of delivering care is,” he said, which leads to the development of contracts for value-based care.

He showed what color-coded dashboards under the OCM look like and how they helped Mount Sinai identify avoidable admissions among patients with cancer. Mount Sinai now directs patients with neutropenia into a 24-hour ambulatory care center instead of sending them to the ED, for example. Social determinants play a huge role in who ends up in the ED or the hospital. “Not that these are easy things to change, but they are easy to identify,” Isola said. Data point out the need for more investment in social workers who can help these patients deal with housing, hunger, or other stressors.

Mount Sinai fell short of savings targets for the first 2 evaluation periods under the OCM, but the knowledge it gained from looking at data brought dramatic improvement between the second half of 2016 and the first half of 2017. “We’re moving in the right direction,” Isola said.

Making Payment Models Prospective

Payment on volume is not where healthcare wants to be, Karp said. But he acknowledged that having volume allows Horizon, New Jersey’s largest insurer, with 50% of the market, to take on innovations that would not be possible without 3.8 million members. Today, around 4100 physicians and 800,000 members are in some sort of value-based arrangement, he said.

When Horizon embarked on its movement toward value-based care a decade ago, getting specialists to join the primary care physicians was not easy. The first step to bring the 2 groups together was bundled payments, which Karp said included an underlying fee-for-service payment with targets around quality and an upside bonus. Today, more than 1000 specialists have signed on and Horizon has seen $45 million in savings, with half going back to the physicians. Next came ACOs, and Horizon contracts with 8 throughout New Jersey.

The big step was the OMNIA Health Alliance,7 a controversial move in which Horizon formed partnerships with 6 health systems and a large physician practice to enter into long-term value-based partnerships that included data sharing, along with financial terms that called for the partners to accept lower reimbursements in exchange for anticipated patient volume. “These were not standard hospital contracts,” Karp told the IVBM audience. He said Horizon wanted partners with the same vision and that there’s been significant progress.

How do Horizon’s efforts apply to oncology? Karp began with a snapshot of spending trends by cancer type and the bad news that higher spending is not necessarily bringing better quality. Increased spending is being driven by demographic shifts, new treatments and genomic testing, and more imaging. According to his presentation, of the $2.8 billion that Horizon spent on oncology claims in 2017, breast cancer accounted for 17.4%, followed by skin cancer (11.5%), prostate cancer (9.3%), pulmonary (7.9%), and lymphoma (5.9%). There are still significant disparities in cancer screening, which Karp said Horizon is working to address through direct contact with employers by offering screenings at the workplace; Horizon does additional outreach through community relationships and through social media.

Karp also discussed the new payment models that will leverage the data gathered with COTA, which will take effect on January 1, 2019. “We have used claims data to build our bundles, but we didn’t have the clinical data available to us,” he said. “Now, we do.” Combining the sets will provide “a much more sophisticated view of the of how the bundle was built.”

But Karp said the better modeling is only one piece of convincing physicians to take on more risk. Building trust is just as important. “We can’t do this if we have a relationship that we used to have, where we pay the bills and we argue over contract rates. That’s not the way it works. We work collaboratively. We have meetings weekly, monthly. We develop things together with our provider partners. That’s the only way it’s going to work.”


  1. Verma S. Pathways to success: a new start for Medicare’s accountable care organizations. Health Affairs blog. healthaffairs.org/do/10.1377/hblog20180809.12285/full/. Published August 8, 2018. Accessed October 2, 2018.
  2. LaPointe J. How Part B drug changes could impact provider reimbursement. RevCycleIntelligence website. revcycleintelligence.co/news/how-part-b-drug-changes-could-impact-provider-reimbursement. Published July 3, 2018. Accessed Oct 2, 2018.
  3. COTA Nodal Address System. COTA Healthcare website. cotahealthcare.com/cna-system. Accessed October 2, 2018.
  4. FAQS: physician-focused payment model technical advisory committee. US Department of Health & Human Services website. aspe.hhs.gov/faqs-physician-focused-payment-model-technical-advisory-committee. Updated March 7, 2017. Accessed October 2, 2018.
  5. Oncology Medical Home Recognition. National Committee for Quality Assurance website. ncqa.org/programs/health-care-providers-practices/oncology-medical-home/. Accessed October 2, 2018.
  6. Quality Oncology Practice Initiative. American Society of Clinical Oncology website. practice.asco.org/quality-improvement/quality-programs/quality-oncology-practice-initiative. Accessed October 2, 2018.
  7. OMNIA Health Alliance. Horizon BCBSNJ website. horizonblue.com/about-us/news/press-kit/omnia-health-alliance. Accessed October 2, 2018.

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