Providers Move Forward With 2-Sided Risk and Take on Pharma

October 29, 2019
Mary Caffrey
Mary Caffrey

Heading into 2019, the idea that oncology practices would fully embrace financial responsibility for clinical decisions still seemed far-fetched for many. And yet, when it was time to make the call, moving to 2-sided risk proved a “simple” decision, said Travis Brewer of Texas Oncology, who took part in a panel offering an update on the Oncology Care Model (OCM) at the start of the Community Oncology Alliance (COA) Payer Exchange Summit, which opened Monday in Tyson’s Corner, Virginia.

Heading into 2019, the idea that oncology practices would fully embrace financial responsibility for clinical decisions still seemed far-fetched for many.

And yet, when it was time to make the call, moving to 2-sided risk proved a “simple” decision, said Travis Brewer of Texas Oncology, who took part in a panel offering an update on the Oncology Care Model (OCM) at the start of the Community Oncology Alliance (COA) Payer Exchange Summit, which opened Monday in Tyson’s Corner, Virginia.

This limited gathering of payers, providers, pharmaceutical leaders, and heads of employer coalitions—whose presence has grown at the event—is designed to focus squarely on payment reform in cancer care as community practices seek ways to stay independent amid competition from health systems.

Moderated by Basit Chaudhry, MD, PhD, of Tuple Health, the opening panel brought insights from Brewer and from Terrill Jordan of Regional Cancer Care Associates (RCCA), another large, multisite practice that decided to move forward with 2-sided risk in time for a December deadline imposed by CMS. The deadline, first set for October, calls on practices in the OCM to take stock of where they are and move from so-called 1-sided risk—in which they share in savings gained from efficiencies—to 2-sided risk, which means the practice takes on responsibility for total cost of care, subject to limits.

Jordan said the decision fit with both RCCA’s strategic mission and where the market was heading. The practice had taken on many of the other elements that affect cost—and the big one left was drug costs. “Two-sided risk was always looming,” he said. “Was this the right time?”

Brewer said many analyses went in Texas Oncology’s choice, which took effect July 1, but the decision was similar. The practice had succeeded with clinical pathways and was seeing savings from the OCM performance periods, so moving to 2-sided risk seemed to be the next logical step.

Other payers, not just Medicare, would want 2-sided risk. “It’s coming, and we need to be out in front of it,” Brewer said.

Both Jordan and Brewer discussed the importance of physician leadership through this process, because it’s the oncologists themselves who stand to lose money out of pocket if practices don’t change. The process of getting to where RCCA’s oncologists are today, Jordan said, is “a journey in itself.”

“In 2012, if I had said we are going to 2-sided risk, I would not have a job,” he said. “Today, I say, we’re going to 2-sided risk, and they ask, ‘how?’”

Along the way, RCCA has developed many strategies, and Chaudry pressed Jordan to explain a tactic the practice uses called “surrogate reporting.” There is a long lag between actual episodes and when CMS returns data to practices, and Jordan said RCCA realized at the outset that it was essential to have a handle on where the costs were accumulating, and where resources had to be directed to keep patients out of the emergency department.

This was a tall order, because RCCA’s internal systems had been set up to handle claims, not help make predictions.

But the biggest change has come in the way RCCA approaches its talks with drug makers. No longer content to wait for the payers to negotiate prices, Jordan said, the practice sat down to talk price directly with the drug makers. Many of them are located in New Jersey, where RCCA has a huge footprint.

Jordan said RCCA was blunt. “You don’t want to be on the list,” he said. “Ultimately, we told the manufacturers, you haven’t had to participate in risk…you’re participating in risk through us now. If you’re not our partners, you’re our target.”

Brewer agreed that time for direct action has arrived. He said in his prior role on the payer side, there are “3 types of people,” when it comes to value-based contracting: those willing to collaborate, those who will do it “kicking and screaming,” and those who “want no part of it.”

“The ones who want absolutely no part of it are going to be standing out front when the tornado hits,” Brewer said.

Chaudry asked for more details on gaining physician buy-in, and Brewer said since the move to downside risk, “You find that clinicians are more engaged. They’re all showing up to the meetings,” on how this will be executed.

“What are the spirited conversations about?” Chaundry asked.

Jordan offered examples such as navigating which biosimilars are in which payer contracts. When things get that specific, “you’re messing with clinician time, and the currency of the clinician is their time,” he said. Any errors lead to a “hit to the pocketbook.”

“This is something that hits to the very core of practice,” he said.

Brewer agreed. “We can’t stock 4 different biosimilars for 4 different insurers. It doesn’t make sense financially,” he said. “If you’re going to trust us to take the risk, then you have to trust us to have a voice in these overall decisions.”

Chaudry asked if either practice had dealt with reinsurance in the transition to 2-sided risk, and neither had; Jordan said the products are too new and not properly priced.

So, where do value-based models go from here? There is considerable speculation—and concern—about what will happen when the OCM reaches the end of its 5-year run.

“Payer models have started to coalesce around something that looks like OCM,” Jordan said. He expects that CMS will continue to drive the direction of future value-based designs, and it will be hard for commercial payers to veer too far from the Medicare model.

No matter what, Jordan said, the OCM has forever changed the landscape in decision making in cancer care. It assumes that the right place to make clinical decisions is at the level of the provider. “That’s fundamental,” he said.