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Practice Pathways Under the Oncology Care Model



Bruce Feinberg, DO: So beyond that, which is I would have called the back-office piece, there was a front-office piece too. Rich, often that front-office piece had a lot to do with the clinical pathway itself. How are these patients going to be treated? I’m curious because, again, you’re in an institutional setting, but not every patient can go on a research protocol. Are those patients all one-off, or are those patients not on protocol still on a protocol in our pathway? It’s just the other—it becomes the OCM [Oncology Care Model] related to a practice pathway for those not eligible for a trial.

Richard D. Carvajal, MD: Obviously, I think the emphasis on guideline-based management is paramount, and that’s another emphasis of this program.

Bruce Feinberg, DO: Yeah, but is this guideline NCCN [National Comprehensive Cancer Network]? And can it be level 1 or level 3? If it’s a NCCN, it flies, or is it much more restrictive than that?

Richard D. Carvajal, MD: No, for us, I don’t feel constrained in any way, in terms of management from the program. Although guidelines are emphasized, we do have a lot of leeway in how we manage patients, whether it’s part of standard of care or on clinical trials. From my perspective, something I’d be interested to hear from the rest of the panel is, what is the impact of this program on clinical trials? Because again, from my standpoint, clinical trials play such a major role in the care of our patients.

Bruce Feinberg, DO: It’s a good question. Kavita, we do have performance metrics. We’ve had 2 reports now. We had the initial 2-year benchmark report and the subsequent report in December 2018.

Kavita K. Patel, MD, MS: Right. There are 3, actually.

Bruce Feinberg, DO: Oh, the third is out?

Kavita K. Patel, MD, MS: Yeah, about a month ago.

Bruce Feinberg, DO: The third is out, OK. What have we learned so far?

Kavita K. Patel, MD, MS: We’ve learned that drugs are more expensive.

Bruce Feinberg, DO: More expensive than we thought?

Kavita K. Patel, MD, MS: Yes and no. I don’t think anybody on this panel needs to be educated that drugs are more expensive, but I think that something that has been surprising is that the rate of increase of Medicare Part D drugs, especially cancer drugs obviously, are at a higher clip rate than Part B, as in drugs. Everybody keeps talking about physician infused—the old adage that chemotherapy was someone sitting in a chair for hours—and checkpoint inhibitors. We’re seeing a dramatic change in just the advent of oral and immunotherapies that are readily convenient and accessible to the patient in all kinds of cancers. That’s a big kind of news flash from the OCM results.

Ted Okon, MBA: Let me put some numbers on what Kavita just said, which are really startling. If you look at the increase since early 2012, if you look at the increase in costs and prices, Part B is 26%. Part D is 280%. If you look at the components that affect the OCM in terms of drugs, and if you look at service costs and everything else like that, they’ve absolutely stayed roughly the same. They’ve only increased a little bit. But what’s really increased is the Part D thing. I want to go back to something that Rich said because he asked about clinical trials, but before that you started talking about pathways. I get to look at a large number of practices, and the interesting thing in this is if you look at the spectrum of practices, they’re all implementing it differently. They’re implementing it differently, especially in terms of pathways because they haven’t been handed the way an insurer would hand them a pathway and say you must follow that. They’ve implemented their own pathways, and I think the practices that have been successful also have tried to narrow down those pathways, not guidelines.

Bruce Feinberg, DO: You’re saying pathway. Pathway is more restrictive than the guideline.

Ted Okon, MBA: Yeah, absolutely. Pathway is more restrictive than the guideline. But what I’m saying is that’s provider driven. That’s not the government handing down and saying you shall follow this pathway.

Bruce Feinberg, DO: Right. Kavita, as a policy expert and somebody who also, by virtue of your background, maybe sees more population health aspects here, you would think if everyone is doing their own experiment in a federated model…wouldn’t there be 1 that would be better? Shouldn’t, at some point, it come out of this that there’s a best way or there are 3 best ways? NCCN finally got to preferred regimen, so you don’t have 20 for adjuvant breast. You’ve got 3 that are preferred. Is there an attempt to try to get to that point from this?

Kavita K. Patel, MD, MS: Attempt by whom?

Bruce Feinberg, DO: Right.

Kavita K. Patel, MD, MS: Attempt by the government? Probably not, because I just don’t think any administration would like to say that they’re…the headline could write itself, that the government is forcing cancer doctors to prescribe only certain medications. That would be a disaster. But to your point, I actually think other payers are paying very close attention. Certainly, large national payers have already, as Ted mentioned, said, “Here’s your prescribed pathway. You must go use it.” But we’re now seeing even more emphasis on how we manage the pharmaceuticals and third parties that are, quite honestly, so much better at doing it than any doctors and insurers I know. So we’re seeing enough interest in that space.

For clinical trials, I would say a deep flaw of this program is that you can be in the OCM. A patient can be in the OCM, as you know, and be on a clinical trial as long as the “drug,” the Part B or Part D cancer drug that triggers the episode, is not part of the trial. It can’t be drug XG123; it has to be pembrolizumab— I’m just making that up. The flaw in this is that there is still a reluctance because there is a way to do it, from a policy standpoint, to incorporate people who actually are on a drug that’s part of the trial. But I think that was 1 of the areas that was said that’s not a priority right now. I think that’s a mistake because I think more and more doctors—I would say the Columbia’s of the world, the Johns Hopkins’s of the world—know that cancer predominantly goes on in the community. Community doctors are leading trials, so we need to find a way to make all this work.

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