A Review of the Treatment for Multiple Myeloma - Episode 23
Ola Landgren, MD, PhD: Do you think the payers could start putting pressure on drugs saying that you need to show MRD [minimal residual disease] negativity in order to get clearance for reimbursement?
John Fox, MD, MHA: No. I think, again, if it’s FDA approved and it’s in the NCCN [National Comprehensive Cancer Network] Guidelines, we’re likely going to do that. Mount Sinai Health System in New York, New York, is in this arrangement, and about another couple of hundred practices around the country are in this Oncology Care Model [OCM] with CMS and CMMI [Center for Medicare & Medicaid Innovation], where they’re bearing financial risk for the total cost to care for these patients. When the practice, or the institution, is bearing risk for the total cost of the care, how is that influencing their decisions on what regimens to use?
I know in our community, where there’s a practice of 25 oncologists who are bearing risk through the OCM—and right now it’s gain sharing only—if they beat the Medicare budget, they get to share part of the savings.
They’re looking at what you were talking about, Sundar, which is decreasing the frequency in relapsed-refractory patients from twice a week carfilzomib to once-a-week, or daratumumab containing regimens and eliminating the other drugs and just going to daratumumab in those relapsed-refractory patients.
It will be very interesting in the future, especially if more practices and more institutions are bearing financial risk, to see how that risk translates into changes in treatments for their patients, especially on the back end, when we get patients into MRD.
Ola Landgren, MD, PhD: If I understand you correctly, is that model based on the fact that there is a financial incentive on our holding back unnecessary resources?
John Fox, MD, MHA: Well, sure. It’s not only on drugs, and it’s probably the least on drugs. It’s how we avoid hospitalizations, how we avoid ED [emergency department] visits, how we use HOPA [Hematology/Oncology Pharmacy Association] Guidelines to optimize drug dosing in patients for whom the drug is based on body surface area or milligrams per kilo. All those things are playing into how we improve outcomes and reduce non—value-added care? In this space, I would say, as we talked about earlier, if we’re doing transplants in patients where we can’t demonstrate the value of that, is that unnecessary or wasteful care? People don’t like to use the term waste, but if it’s not adding value, or if we can’t demonstrate the value, it’s probably a fair word to use.
Ola Landgren, MD, PhD: What would happen in this model if the patient says, “I happen to know that there was a guideline that says I have the right to receive this. I want to do it.” Would that be something that the institution would say no to?
John Fox, MD, MHA: Well, you’d have to ask. You’re the institution; not me. But I think there’s actually no incentive not to follow the evidence. I think when the evidence is unclear, Sundar, as you said, you’re using your clinical judgment of 5 years of some drug. I think physicians are being forced to think more critically about how they’re treating patients, especially when there isn’t evidence that exists.
Sundar Jagannath, MD: Yeah. I mean, for my institution, because you say we are 1 of the institutions, it has not had any impact. The institution doesn’t become—there hasn’t been a meeting with us to come and say, “Hey, guys, you are all in this” what do you call it?
Ola Landgren, MD, PhD: OCM—Oncology Care Model.
Sundar Jagannath, MD: OK, “Oncology Care Model, and that you should change your practice, etc.” We are still evidence-based driven, even when we care for patients. That’s 1 aspect of vigorously participating in clinical trials. All the physicians are trained to do clinical trials. Even the patients who are not eligible for clinical trials, we approach them in a similar fashion. We provide them with the best of care.
But I agree that we generally don’t like bringing the patient to Mount Sinai emergency department because it’s always overcrowded and our patients always complain. We have tried to avoid bringing them to the emergency department for that particular reason. We’ve also started saying that we could provide them care in other ways like the 24-7 infusion center. That is where they can come and get some treatment or something like that. So we are looking at it a different way. But at the bedside, as you said, we still practice evidence-based medicine, and there is no directive in terms of...
Ola Landgren, MD, PhD: But are there any incentives built into the models of the benefit program?
Sundar Jagannath, MD: That’s what I’m saying. We have not even had a visit from the people who are contracting with OCM. We were just told it is observational, and they are just capturing what we are doing, but they have not impacted on how we care for the patients yet.
Ola Landgren, MD, PhD: There is a simple way of opposing it. You are saying that the payers and the physicians are on the same page when it comes to the user resources, based on what you are saying here.
Sundar Jagannath, MD: Yeah. I mean the payers are, but we still have third-party payers and all these types of things. It’s just the Medicare is in the…
John Fox, MD, MHA: Just to be very clear, the OCM was set up as an experiment to understand whether putting physicians at risk, and potentially sharing and savings, could reduce the total cost of care for treating patients with cancer who are Medicare beneficiaries. The hope is that we can drive out non—value-added care. The ER [emergency department] risk is the hospitalizations, end-of-life care, where patients might be better off in hospice than getting ongoing treatment. So that’s the low-hanging fruit. Drugs are hard.