Immunotherapy in the Oncology Care Model - Episode 10
Bruce Feinberg, DO: Rich, Ted brought up value. But the classic equation for a clinician is a quality-cost equation. But quality is toxicity and efficacy. What I think is different among these different classes as we start to move forward, of novel drugs or drugs with novel mechanisms of action, has been the toxicity component. I alluded to it earlier about walking into a waiting room and the different profile. If there isn’t a rational exuberance, which some have said about I-O [immuno-oncology], it’s related more at the toxicity level than even the efficacy. I wanted you to touch on that because I think that’s why as big a push as there’s been around precision medicine, it didn’t capture the attention of the treating community the same way that I-O has.
Richard D. Carvajal, MD: It’s really remarkable now because we have patients for instance on adjuvant immunotherapy drugs, and this is already a relatively healthier patient population receiving a drug that in many cases has minimal or no toxicities, maybe a little bit of tiredness, and maybe a little bit of joint pain. What I hear sometimes is that the worst part for them is coming in and sitting in the waiting room with all the people who are sick. This is because there are still people getting standard chemotherapy or some of these targeted agents with more toxicities and so forth.
They really see themselves as receiving a completely different type of therapy. The quality of life from a treatment-toxicity perspective is dramatically improved. Something that is clearly a big emphasis in the field is to have you demonstrate that value and have you document that value. As practitioners, we can tell you this is valuable to patients. Patients are telling us that value certainly has to be captured and documented.
Bruce Feinberg, DO: The basic metric that was developed—in what, 1968?—around dialysis, is the quality. Now we’ve got a couple of different factors with the quality because we not only have an efficacy component but we have a significantly differentiated toxicity component. And we’ve got this potential that you can tell the curve is flattening where you have a 20%, 30% cure rate.
I don’t even know. It’s in 3.0 or 4.0. But because you don’t have these benchmarks until so late, you almost get into a different concept in insurance in which you literally get payments at year 1, you get a third at year 2, and if you make it to year 3 and beyond, you get your full payment, which is problematic for everyone involved because we’re not designed for that. But it seems that part of the constraint of whether it’s a 6-month episode or almost any episode—when it comes to cancer care, I totally get it. When we’re talking about OB [obstetrics]—and you’re trying to wrestle with the variance between what can be a single digit, C-section rate versus a 50%-plus C-section rate in certain communities, or with a joint replacement—as an episode of care, it’s pretty straightforward.
I don’t know how you do it in cancer. When you get into these different models, is it the right solution at all? Should there even be a 4.0 or a 5.0, or is it the wrong way?
Ted Okon, MBA: No, I think there has to be a 2.0, a 3.0, a 4.0, and a 5.0. I think we have to do a better job at measuring quality and what we’re talking about by quality. I think we have to do a better job in terms of measuring that as a part of the care-delivery process, not as something that has to be entered manually into the process. We have all that now. I think we have to get smarter about that.
The other thing is that there are a lot of different models out there, Bruce. If you look at what is being proposed in, for example, Louisiana, they have adapted the Netflix type of model, in which you buy a subscription just as you would for Netflix. You and I are paying the same, but basically you can watch 1 movie a month and I can watch 20 movies a month.
Bruce Feinberg, DO: We’re paying the same, and you get 20 movies, but I get only 1?
Ted Okon, MBA: Oh no. Netflix says you pay your whatever it is now—$12, $14, whatever—but you can use it as much as you want.
Bruce Feinberg, DO: Right.
Ted Okon, MBA: The whole idea is applying that to the drug side and Louisiana Medicaid. My point is that we need to get better in terms of what we measure and understanding what we measure, but we’ve got to get even more creative in terms of how we go about this. Because I can tell you, and you mentioned it before, on the way down here I was doing a very interesting interview with a reporter who actually is a 2-year survivor, who went through CAR-T [chimeric antigen receptor T-cell therapy] as part of their clinical trial. I was asking these questions. And part of it is asking it in terms of this proposed NCD [national coverage determination].
How do you deal with the fact that just on the drug side, you roughly have 400, 500? What’s another $100,000 among friends for the drug, let alone all the hospital costs and all that? But the point is, these are very expensive. How are we going to deal with that? We’re not going to deal with it by paying ASP [average sales price] plus 6, which is the Medicare reimbursement rate. My point is, we should be smarter on the measures and smarter on some on some of the arrangements for how we think about this in terms of paying for value.
Richard D. Carvajal, MD: I think the value also has to go beyond just looking at what we’re saving in terms of patient care from the patient’s perspective, because another thing that I think we’re saving on is looking at the patient-care providers, and the fact that patients continue working through their therapy. They don’t have family members having to look after them. The family members can continue to work. There are added benefits to immunotherapy and some of these novel therapies that would be amazing if we could capture it in terms of the value measurements.
Bruce Feinberg, DO: Wasn’t that one of the surprises of the cost profile in terms of drugs within the OCM [Oncology Care Model] Performance Review: the fact that you’ve missed what is the largest contribution typically of hospital-based cost is the diagnosis?
Ted Okon, MBA: Right.
Bruce Feinberg, DO: You’re looking past that point. You’ve taken a huge cost factor and you’ve removed it, and you look at the point in which they’ve seen the medical oncologist and initiate their adjuvant or metastatic therapy.
Kavita K. Patel, MD, MS: By the way, that’s a big tension point because many people wanted to push—and Ted knows this—including me, to include diagnosis just because I think there are too many people. I can tell you that sometimes by the time they come to Rich, they’ve either had the wrong diagnosis, a misdiagnosis, wrong treatments.
Susan Ash-Lee, MSW, LCSW: Absolutely.
Kavita K. Patel, MD, MS: There are a lot of people who a selection bias happens to at large tertiary and quaternary centers. At Mayo Clinic, they think it might be as high as about 9% to 10% of their patients with cancer have the wrong diagnosis. I actually pushed and said diagnosis should be part of this. Honestly, it was too complicated because cancer diagnosis happens, and not just the medical oncologist purview obviously, but I would almost say that for time on immunotherapy and value, we actually know that not enough patients are getting immunotherapy. This is in part because of this cascade of events that lead them to either not getting tissue sent for NGS [next-generation sequencing], as well as understanding where targeted therapies would apply. I would say the OCM misses all that.
Ted Okon, MBA: One of the things is, and Susan should comment on this, we always talk about value. It’s always from the provider’s perspective. But who’s getting treated here is the patient. We don’t do enough from the patient perspective in terms of what they perceive as value to that.
Susan Ash-Lee, MSW, LCSW: That’s right. The cancer-support community is in the midst of a study of focus groups for OCM patients to talk about if they know that they were enrolled and what it meant. Did they get any value from it?
Ted Okon, MBA: How would they know if they got value, since they don’t have a comparator?
Susan Ash-Lee, MSW, LCSW: But value is something that often is very personal to me.
Bruce Feinberg, DO: This is why clinicians have so much trouble with this.
Susan Ash-Lee, MSW, LCSW: That’s right.
Bruce Feinberg, DO: Yeah.
Susan Ash-Lee, MSW, LCSW: That’s right. But for patients, how they describe value and how you, as oncologists, would describe value often are not even in the same hemisphere. Right? How do we get those worlds a little bit closer, describing that in a more specific way? I think what patients want is to know that their worries about the future are going to be attended to, that they can continue to work, and they can continue to participate in the life that they loved before. Often they do not understand that certain treatments might interfere with that. Sometimes temporarily and sometimes permanently from an I-O perspective, we’re seeing folks’ outlook and ability to remain connected to the normal ways in which they like to live are more tenable, right? But that isn’t true for all of the other treatments out there.
Bruce Feinberg, DO: But it seems to me that there is a clear choice in that OCM put the measures in place in order to have a greater focus on patient centricity. But there was no call-to-satisfaction survey component to the performance metric as a determination of how well the practice is doing.
Kavita K. Patel, MD, MS: No, there is a patient satisfaction survey. It’s unfortunately very long and cumbersome, in my opinion.
Susan Ash-Lee, MSW, LCSW: Eighty-five questions.
Kavita K. Patel, MD, MS: It’s completely clunky; I was a survey researcher. An 82-element survey for a patient who has cancer is probably the most asinine thing you can do.
Bruce Feinberg, DO: So it was required? How was that incorporated into performance review?
Kavita K. Patel, MD, MS: It was originally going to be part of a factor for your performance-based payments and participation. There was this kind of float out there that sometime in the 5 years, your performance on those surveys would affect your scores. But it’s not to your point, Bruce. I’ll say this. The key performance measurements are utilization driven and have been started in the OCM. I would say that’s exactly where every payer congregates—that utilization measures want to get the highest priority.
Susan Ash-Lee, MSW, LCSW: Am I correct that not all patients get the survey?
Kavita K. Patel, MD, MS: They were supposed to have every patient get the survey, and now I forgot the percentage.
Susan Ash-Lee, MSW, LCSW: Yeah. You don’t have that really great aggregate data, and who’s going to take an 82-element survey?
Kavita K. Patel, MD, MS: Right.
Susan Ash-Lee, MSW, LCSW: Those are going to be folks who are really motivated to give you feedback.
Kavita K. Patel, MD, MS: Right.
Susan Ash-Lee, MSW, LCSW: It will either be because they love it, or they’re really not happy.
Kavita K. Patel, MD, MS: But all Medicare patients are getting surveys, so the OCM has not replaced it. Most people are using Press Ganey Associates, Inc, as a third party. But every Medicare beneficiary— after they see anybody in the clinic setting—is getting what they call a CG-CAHPS [Clinician & Group Consumer Assessment of Healthcare Providers and Systems] survey, which is a satisfaction survey. Doctors hate that also, including me, because it asks about things that I can’t control, like wait times and—well, I can, but I don’t like to.
Bruce Feinberg, DO: To some degree you can, and to some degree you can’t.
Kavita K. Patel, MD, MS: It controls things that don’t feel like they’re in your purview, yet you’re being held to a metric. My hope, in talking about the next of phase OCM, is how do we get to a better sense of what patient-related outcomes measures really are? How do we meaningfully integrate that into actual payment models as opposed to ones that are utilization heavy, and patient satisfaction surveys that are largely meaningless?