Immunotherapy in the Oncology Care Model - Episode 7
Bruce Feinberg, DO: I want to get back a little bit because with the OCM [Oncology Care Model], we’ve talked a little bit about pathways and other initiatives that are all part of it. Susan, it seems that if practices are changing what they’re doing from a patient advocacy perspective, there would need to be some declaration that we’re participating, not just that we’re doing better. On 1 hand, you could say that a practitioner would say, “I’ve always followed some kind of a pathway. It’s an in-house pathway. It’s the pathway that I was trained in. It’s NCCN [National Comprehensive Cancer Network] Guidelines.” But it is a bit different in the OCM. What is the guidance that practices are given if any, and who provides that guidance? How do you approach this process? If you’re truly patient-centric, how are you communicating that we’re in this program?
Susan Ash-Lee, MSW, LCSW: That’s right. Well, that’s 1 of the fundamental things that those OCM practices need to do. They have to tell the patients that they’re being enrolled into what is called the Oncology Care Model.
Bruce Feinberg, DO: But there’s no formal consent they’re signing to do so.
Susan Ash-Lee, MSW, LCSW: That’s right, but there is an approach in which everyone should be receiving a letter, an information guide. Each practice has been challenged to decide how that’s going to be rolled out. But absolutely everyone needs to demonstrate that they’ve given that to the beneficiary. Some practices are using their navigator up front, and they are sitting down with those patients to describe what the OCM is and isn’t. Other practices are sending a letter, and so you can imagine that there are going to be really different outcomes with those 2 sorts of practice: 1 that’s more dynamic and engaged and 1 that’s a little bit more passive and checking a box.
Bruce Feinberg, DO: Rich, if they’re participating, now they’re going to be measured in episode of care. Is that concept even described? Is it necessary that they’re being measured in some way, that they’re being assessed, or that there is an assessment based on a 6-month period? Or are we saying that I’m putting you on this therapy, and the 6 months is irrelevant to what I’m doing?
Richard D. Carvajal, MD: The 6 months, in my mind, is a fairly arbitrary number. It doesn’t actually capture the kind of history and the natural course of the disease or how we practice. So that’s not something I emphasize in any way. The goal is to capture if we are actually making things better, but the time period in my mind is a little bit arbitrary, and it’s not something I talk to my patients about.
Bruce Feinberg, DO: But Kavita, it’s not arbitrary from the standpoint of the metrics by which the performance is being measured.
Kavita K. Patel, MD, MS: Right. The measurement period is 6 months, so it’s arbitrary in a very true clinical sense; it’s not arbitrary from a payment sense.
Bruce Feinberg, DO: There are a lot of great minds that were wrapping their heads around this. What was the thinking, if you know at all? Because, you probably sat in some of the interesting conversations. Rich was talking about the fact that he now sees melanoma patients for whom he’s thinking about cure even though they’re metastatic. How do we think about the cost of the 6-month episode in which that choice made about that 6-month episode could relate to 3-year, 5-year, and 10-year survival differences? In a different system or in a different business line, you would amortize that cost over the duration of the benefit. Here we’re looking at it in this kind of arbitrary way. But I’m sure that people talked about it and thought about it. However, medicine is changing quickly in light of the novel therapeutics that have been introduced.
Kavita K. Patel, MD, MS: Ted will tell you that because he was in some of those rooms and nobody talked about it. But I don’t think it was because of any explicit malicious desire to not think about it. I’ll just be honest. Even from when I started my training, and it now feels like a long time ago in a galaxy far away, we didn’t have much beyond platinum. There just wasn’t much to give patients. For policy makers who have zero clinical expertise themselves, in general, I think they need to think through that.
I would say the 1 thing that CMS did is this novel therapy adjustment. A lot of the immunotherapies that have emerged fall into that category. The 1 policy thing that I do think was the first step at what you’re talking about, Bruce, was to actually say, “Listen, we get that in cancer, there are lots of new drugs, and we’re going to treat the prices of those new drugs a little differently.” What they were trying to do was nuance not having a doctor feel like they shouldn’t prescribe life-saving therapies just because they’re new and costly. But then they also wanted to recognize that we don’t want to just go prescribe anything you want, regardless of the evidence. That was what they were trying to thread.
Ted Okon, MBA: But the interesting thing is that when this was developed and devised, they weren’t thinking about the impact of the IO [immuno-oncology] drugs.
Kavita K. Patel, MD, MS: And the survival.
Ted Okon, MBA: The cost of the IO drugs.
Kavita K. Patel, MD, MS: Correct.
Ted Okon, MBA: They weren’t even thinking about, as Kavita said, “Bruce, what you’re talking about is 3, 5, 7 years down the road in terms of survival.” What’s interesting about it, even though Kavita is absolutely right that they put in this novel therapy adjustment to take into account these novel therapies, is that they didn’t have any indication of the impact that the IO drugs would have. As a result of that, price prediction is a big problem with this model because the underlying prices do not reflect and are not adjusted enough for some of these new therapies, specifically in terms of IO. It’s a real problem in that you’ve got a program that—I know practices that have done an amazing job keeping people out of the emergency department, keeping people out of the hospital, and all of that, but have gotten hit on some of the drug costs specifically related to this problem of underlying price prediction. Depending on what your mix is of patients, including patients on IO drugs and Medicare Part B versus Part D, the dynamics are really crazy here. That’s what is not down yet at all and is 1 of the biggest flaws of the model.