Coverage from the Minnesota meeting of the Institute for Value-Based Medicine, chaired by Rajini Katipamula-Malisetti, MD, vice president of medical oncology at Minnesota Oncology.
How do we define value in cancer care?
For Krista Olsen, MD, and Justina Lehman-Lane, DNP, CNP, it meant a sharp turn from care delivery that started with charts instead of patients. Instead, Olsen, an obstetrician/gynecologist in Edina, Minnesota, and Lehman-Lane, vice president for clinical innovation and value-based care for the Infinite Health Collaborative (iHealth) in the Twin Cities area, overhauled what happened when a patient from Olsen’s practice received bad news following a mammogram—they made sure they could follow that patient as she connected with an oncology care navigator for follow-up.
For Joleen Hubbard, MD, a medical oncologist at Mayo Clinic in Rochester, Minnesota, “value” includes the relationship with Minnesota Oncology that lets local providers get a web-based second opinion without requiring the patient to travel.
For Paul Forsberg, PharmD, MHA, director of pharmacy at Minnesota Oncology in St Paul, there’s value in the rise of medically integrated dispensing, which allows for real-time adjustments to dosing based on a patient’s lab results so that expensive oncology drugs are not wasted.
These were among the examples discussed recently at Delivering High-Quality Cancer Care Across Community Partners: How It’s Done! Minnesota Oncology presented the event through the Institute for Value-Based Medicine®, an initiative of The American Journal of Managed Care®.
Rajini Katipamula-Malisetti, MD, vice president of medical oncology at Minnesota Oncology and chair of the event, opened with a story about her mother’s trips to the market in India, where bargaining with vegetable vendors meant striking a balance between quality and price—and making it worthwhile to walk the distance twice a week.
Just as her mother worked to strike a balance, Katipamula-Malisetti said that physicians, too, must find that balance despite many barriers, from prior authorization to transportation to scheduling.
“When the patient is diagnosed with cancer, the biggest thing is the word itself—it just stops them in their tracks,” she said. “There’s difficulty getting the patient in to be seen by a specialist, to gather tests, to get a PET scan image. [There are] always hurdles. How can we get through this? How can we work together within our community, across different disciplines?
“It is the patient that we work for. How do we best care for our patient?”
“Holding the Hands of Our Patients”
Olsen recalled the days before she grasped the idea of “value-based care.” She was busy being on call, finishing charts, and checking all the right boxes. “Somehow that mammogram was getting done, and the person was going to do it,” Olsen said. “And when people would bring up value-based care or patient-centered care, my ears went a little sideways.”
Back then, Olsen’s patients would go off for that mammogram and not see her for a year, when she would learn for the first time the woman was being treated for breast cancer. Olsen wondered about patients lost in “the system” and about patients who never showed up for the mammogram. It also wasn’t clear whether the results came back to her or the primary care physician.
Connecting with Lehman-Lane and iHealth changed everything. The Minneapolis-based collaborative helps independent practices focus on patient-first care by assisting patients in making choices about referrals and in navigating the health system across 8 areas of care, including cardiology, colon and rectal, women’s health, and family medicine.1
Referrals through iHealth offered Olsen and her patients a different experience: Olsen can do more to ensure high-value, appropriate care, and she can keep track of what’s happening. Sometimes, Lehman-Lane noted, that means evaluating who doesn’t need expensive tests or consults. For example, not every patient needs genetic counseling.
Lehman-Lane pointed out an oncology navigator in the audience who does an outstanding job “hand-holding” patients when they have questions or need help setting up appointments. This type of personalized service is especially important. “I’m from rural Minnesota, where you can see your physician in the grocery store line,” she said. “Then I got into the real world, and I realized it’s a chart being handed around. It was patient numbers. And leadership says, ‘How many mammograms did you order? How many patients did you send to genetic counseling? We want to build a surgery center—can you fill it?’
“And now, we’re taking it back to what we all went into medicine for—which is holding the hands of our patients and their families.”
“Sharing” Mayo Clinic Through a Partnership
The original Mayo Clinic campus in Rochester, Minnesota, was founded on the idea of putting patients first, Hubbard explained. William J. Mayo, MD, one of the founder’s sons who helped grow the multidisciplinary clinic, once said, “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary.”2
Unlike other medical clinics that grew based on patient or procedure volume, physicians at Mayo’s main research and medical centers in Minnesota; Phoenix, Arizona; and Jacksonville, Florida, are paid a salary. Research and education are priorities of Mayo institutions, said Hubbard, who specializes in gastrointestinal cancers and serves on the relevant clinical guidelines panel for the National Comprehensive Cancer Network.
Mayo’s reputation has created phenomenal growth. “Every year, we see about 1.3 million patients from all over the United States and about 140 countries across the world,” Hubbard said. But 10 years ago, the governing board shifted strategy and asked: How do we share what we do with the rest of the world?
“That’s how the Mayo Clinic Care Network was born,” she said. Today, 47 organizations, including Minnesota Oncology, take part—most are medium-sized providers that wish to stay independent while offering patients innovative care. “Their goal is to improve patient care in the communities that they serve and keep patients close to home whenever possible,” Hubbard said. “Our model continues to evolve over time, but the shared values will remain the foundation.”
Minnesota Oncology, which joined the network in December 2020, is the first service line–focused provider to participate, and the partnership is paying dividends. Patients with complex cases can gain reassurance about their standard of care, and clinicians can make use of several tools, which include the following:
The connection to the Mayo Clinic brand is meaningful to patients, Hubbard said. But it’s clinically meaningful as well, and providers at Minnesota Oncology are taking full advantage of network membership. In 2021, during the first full year of the partnership, there were more than 1100 unique AskMayoExpert page view hits by 471 providers; through June 2022, there were 550 hits by 250 providers. There were 82 e-consults through all 2021 and 64 through June 2022. E-tumor board use has soared, with 61 cases through June 2022. “It’s a very well-utilized service,” Hubbard said.
One of the best success stories involved an 81-year-old patient referred to Katipamula-Malisetti. Diagnosed with stage IV colon cancer, the patient had surgery, but a CT scan revealed the cancer had returned to the liver. The patient received chemotherapy, which lowered platelet levels. Katipamula-Malisetti recommended surgery to remove the liver tumors, but the surgeon balked due to the platelet counts. An e-consult with Mayo backed Katipamula-Malisetti’s plan—and a year after surgery, the patient was disease free.
Embracing Biosimilars, Reducing Waste
“Cancer is expensive, and it’s getting more expensive,” Forsberg said as he started a talk on the cost of cancer drugs and what practices can do to offset costs, in part to reduce what patients pay out of pocket. It’s not just therapies delivered by infusion that are becoming more expensive, which for Medicare beneficiaries would be paid for under Part B, but also oral oncolytics, which are paid for under Part D.
Forsberg focused on 2 areas: increasing uptake of biosimilars and the rise of medically integrated dispensing (MID), which he said can save money by reducing waste and improve patient experience by ensuring better management of adverse effects (AEs).
Biosimilars. After giving an overview on biosimilars, Forsberg discussed results from a Minnesota Oncology physician survey, which gauged concerns about switching from a reference product to a lower-cost biosimilar product. “What we found was, physicians—after evaluating the data associated with the FDA approval process—felt very confident in these biosimilar products, and that helped us move forward to that next phase, where we could say, ‘What’s going to be the impact on patients?’”
Most patients, it turned out, are unfamiliar with individual brands of cancer therapies—they just want to know that their doctor feels they are receiving the right treatment. The first strategy considered would have started all new patients on biosimilars when possible.
“But what we found, looking at the treatments, is that it’s about a 10%-per-month conversion rate,” Forsberg said. That meant a lot of confusion for about a year, with added challenges for nurses and practice administrators.
“We’ve got to keep more agents on the shelf to accommodate this.” So Minnesota Oncology ended up expediting the timelines for a switch after reviewing the data and converted patients on reference products to biosimilar products. By January 2022, the practice was 95% converted to biosimilars, and “we were able to capture that value quickly.”
Minnesota Oncology saw no impact on safety. Savings, however, were significant. “When these biosimilars hit the market, we were hoping for an immediate 20% reduction in cost of care, and it’s significantly outpaced that,” Forsberg said.
MID pharmacy. Forsberg described MID as “a fancy term for having a pharmacy located within an oncology practice,” which allows prescriptions to be processed and dispensed on site. But given the complexity of oncology prescriptions, it’s more than that—the services that come with MID offer major advantages. Patients can pick up their drugs during the appointment, and the prescriptions can be turned around more quickly than a national chain, Forsberg said.
Also, direct communication with the treatment team helps avoid AEs. “When we get a new prescription, we can access the electronic health record, we can review the patient’s chart, review their renal function, we can look at their drugs—which is also a significant benefit,” he said.
If there’s a question or something comes back in the patient’s lab results, adjustments can be made before a drug is dispensed, greatly reducing waste. When drugs are shipped directly to a patient, any adjustments require a new prescription, and the shipped drug is wasted.
Forsberg said sometimes patients are authorized for automatic refills, and if the physician discontinues an expensive drug, the patient is left with a prescription that can’t be used. “It’s kind of crazy,” he said. “They’re holding it in their hand, and [asking], ‘What can I do with this? Can you use it for other patients?’ And it’s a complete waste of drug. It’s unfortunate when we see that more than we’d like to see.”
Costs for drugs at an MID pharmacy are the same, but the reduction in waste and abandonment of prescriptions and better AE management—which keeps patients on their therapies—are where the savings and quality improvement happen. Forsberg said results from a pilot with Prime Therapeutics, presented in an abstract at the 2022 American Society of Clinical Oncology Annual Meeting, found there to be less waste for an MID pharmacy dispensing CDK4/6 inhibitors than for a specialty pharmacy.3
Early Intervention and Palliative Care
What are the basic questions in patient-centered care?
Paul Thurmes, MD, executive vice president and medical director for Minnesota Oncology, explored this topic, asking: What does value-based care look like, what are the challenges, and how do we address the challenges?
In cancer care, so many of the issues come down to communication, Thurmes said, outlining what patients want:
Beyond the quality of the care, Thurmes specified a few more things. “They also want to know it’s something they can afford—that they’re not going to go bankrupt,” he said. And they want clinical excellence. “We’re the cheapest” is not the best message for patients, he said.
Coordinating care means organizing data—the biopsy, the x-rays, the genetic testing, and the treatments—and it can be overwhelming, Thurmes said. Electronic health records don’t talk to each other; if anything, there’s been a disincentive to integrate records. And all this has made the cost of cancer care climb, with projections reaching $246 billion in 2030.4 “It’s just an astronomical amount of money,” he said. “It’s put the burden on patients in out-of-pocket expenses, [and] in the cost of taking time off work.”
Thurmes outlined the following 3 strategies for implementing value-based care:
Early intervention. The period right after diagnosis must be well managed to avoid delays in care and overutilization of the wrong care. Minnesota Oncology has created a process that allows a patient who presents in the emergency department to avoid being admitted and, instead, for community providers and the right specialists to have access to records for rapid follow-up, with guaranteed appointments in 24 to 48 hours.
Care coordination. Beyond the process discussed by Olsen for breast cancer, navigators reach out to patients “from the very first moment that they get a referral,” Thurmes said. Minnesota Oncology is very conscious of following up for the second visit “because that’s the [riskiest] time for patients…until they get into the groove of what the system should be like.”
Social workers get involved at this stage. Care plans are developed that look at both optimal treatment and financial toxicity.
Palliative care. Thurmes said Minnesota Oncology actively promotes advances care planning and palliative care, regardless of the stage of cancer at diagnosis. Each patient takes part in a values assessment, which asks, “What is most important to me?” All patients are encouraged to see a social worker, and palliative care and quality-of-life management happen early in the treatment process. Thurmes showed results of a survey about palliative care, and the only patient complaint was that patients wished they had started the process earlier.
During a panel discussion that followed, speakers elaborated on points made in their presentations, and they were joined by Boris Beckert, MD, MBA, senior medical director for provider relations at Blue Cross Blue Shield of Minnesota. He highlighted the basic conundrum of practice transformation: Physicians are not going to change how they do things until the system changes how they are paid.
Building trust and changing mindsets are difficult. “We know we can do a better job for less money,” Thurmes said, adding that advancing the use of bundled payments and better deployment of social workers would have multiple benefits and might ultimately help keep physician compensation at a strong level.
Beckert was blunter. “As the insurance guy, the system drives me nuts,” he said, acknowledging the stress on patients and caregivers alike. “I want you to take care of my dad so I don’t have to.”
1. Independence in health care. Infinite Health Collaborative. Accessed September 24, 2022. https://i-health.com/
2. Mayo Clinic history and heritage; quotations from the doctors Mayo. Mayo Clinic. Accessed September 24, 2022. https://history.mayoclinic.org/toolkit/quotations/the-doctors-mayo.php
3. Leach JW, Eckwright D, Champaloux SW, et al. Medically integrated dispensing (MID) clinical and cost outcomes compared to specialty pharmacies (SP). J Clin Oncol. 2022;40(suppl 16):e18654 doi:10.1200/JCO.2022.40.16_suppl.e18645
4. Mariotto AB, Enewold L, Zhao J, Zeruto CA, Yabroff KR. Medical care costs associated with cancer survivorship in the United States. Cancer Epidemiol Biomarkers Prev. 2020;29(7):1304-1312. doi:10.1158/1055-9965.EPI-19-1534.