Lessons from the first meeting of The American Journal of Managed Care® Population Health Council.
The shift from managing “the patient in front of me” to populations with cancer is in full swing, and health systems have been adjusting to the presence of accountable care organizations (ACOs) and other value-based payment structures for some time.
More than a year into Medicare’s Oncology Care Model (OCM), and with changes to the 340B program on the horizon, The American Journal of Managed Care® convened a meeting of its Population Health Delivery Council on May 11, 2018, in San Diego, California. Chaired by Neil B. Minkoff, MD, the chief medical officer for EmpiraMed, Inc., the council featured Scott Maron, MD, medical director for Atlantic Health ACO; Deborah Welle-Powell, MPA, chief population health officer for Essentia Health; Bhavesh Shah, BPharm, director of specialty and hematology/oncology pharmacy services at Boston Medical Center Health System; Lynne Milgram, MD, MBA, chief medical officer, Sharp Community Medical Group; Debi Reissman, PharmD, senior pharmacy specialist, Sharp HealthCare; John Fox, MD, MHA, medical director, Priority Health; Dan Kus, vice president, pharmacy services, Henry Ford Health System; Despina Garalis, director, population health, Partners Physician Health Organization; Benjamin Kruskal, MD, PhD, medical director, New England Quality Care Alliance; Jonathan Jaffery, MD, senior vice president, chief population health office, UW Health; and Nirav Vakharia, MD, associate chief quality officer, Cleveland Clinic Medicare ACO.
Minkoff opened with a discussion of where ACOs are and how the movement toward population health is going as it relates to oncology. Health systems are still struggling to move oncologists or practices that have been acquired from a system of “everyone doing their own thing” to a standardized one. Pilot programs have helped, but they require significant investment. As health systems integrate with cancer centers, there are more opportunities for standardization. The panelists said the movement toward greater quality and measurement requires both leadership from the top and ownership from individual physicians. And this isn’t a one-and-done proposition. Implementation requires regular gatherings on different aspects of care, review of how the health system will implement clinical guidelines, use of technology, etc.
Early lessons. What has the movement toward population health taught us thus far in oncology? First, standardization has improved care, but it cannot always control costs. Oncologists who want to deliver the most cutting-edge therapies—to extend life by months or years—find that they cannot do so without high-cost therapies. Palliative care is getting more focus than it did in the past, but the council members agreed it’s not nearly enough. The shift from intravenous to oral oncolytic drugs has created a new challenge in oncology: adherence. Patients may not take all of their medication or may not purchase medication that is prescribed, due to cost.
Still a “revenue” item. While ACOs look to contain cancer care costs, most participants said cancer care is still seen by their health systems as a source of revenue—although one said that the “dogs ate our lunch” in a recent ACO contract. They see the tide turning slowly—from a focus on reducing oncology admissions and readmissions to putting a higher priority on care coordination; however, this last point remains challenging, since so many health systems still struggle with how to pay for a service that so clearly helps patients.
What will make care coordination easier without increasing costs? Some see hope in artificial intelligence while others point to better integration of specialty pharmacy into the rest of cancer care. Participants noted that the arrival of new value-based models is creating more reliance on midlevel practitioners, such as nurse practitioners and physician assistants. Recent efforts to reform the 340B drug discount program pose a threat to many hospitals’ bottom lines, the participants warned. Some cautioned that after years of seeing health systems buy up oncology practices that could not compete due to the anticompetitive nature of 340B pricing, pending reforms could force health systems to cut oncologists loose—except their old practices are gone and they have nowhere to go. The “windfall” of 340B is “not what it was,” one said.
Shared decision making. Participants expect patients to have a stronger voice in care decisions, especially in the decision to withhold care. There’s more and more evidence being published on this topic, yet council members said they still see examples where patients are denied the chance to understand all of their options. Too often, the vow to “first do no harm” is interpreted as a call to intervene, one participant said.
But the bigger challenge to shared decision making is cost, which takes many choices off the table. And while drugs are a main culprit, they aren’t alone. Imaging, lost time at work for patient and caregiver, travel expenses, lack of disability coverage, it all adds up. Complex regimens can overwhelm patients, too.
Following guidelines. The National Comprehensive Cancer Network guidelines are increasingly complex, council members said. There are many malignancies for which more than 1 immunotherapy can work, and sometimes therapies can work together, at great cost. Different health systems may have different protocols as a result.
What does implementing the guidelines mean? In oncology, it doesn’t mean a hospital’s physicians follow guidelines 100% of the time—exceptions are expected. Sometimes there are target rates, such as 80%; sometimes systems find out a compliance rate and scale up over time. Then there’s the matter of matching adherence to guidelines with observance to what various payer guidelines and formularies require, and that’s when things get interesting. Tinkering with each payer’s “black box” can be baffling and problematic, and then doing multiple bundled payment programs within 1 hospital can be a nightmare.
Working together. What can payers do to make population health adminis- tration more seamless? Providers were unified: “Give us the data!” The government does a better job giving health systems Medicare data through the OCM than most commercial payers do sharing bundled payment data, yet providers can’t improve without it. Security concerns can be addressed, and they must, if the promise of value-based contracting is to succeed.
What’s ahead? Providers expect more indication-based pricing. The expect oncologists to control every cost they can—and for these costs to go down.