The Unfinished Work of Value-Based Cancer Care

Oncologists, pharmacists, and oncology administrators from across Ohio gathered on May 12, 2026, for the Institute for Value-Based Medicine^® event “Pioneering the Next Era of Oncology Care,” presented by The American Journal of Managed Care®, to assess what has changed in cancer care delivery and, perhaps more crucially, what has not. The panel discussions covered quality improvement over the past 25 years, the pharmacy infrastructure that keeps patients on therapy, the challenge of safely deploying bispecific antibodies outside of academic medical centers, and the operational complexity of bringing biomarker-driven lung cancer care to all patients who need it.

Silos, Survivors, and Prior Authorization: The Unfinished Business of Oncology Quality

In 2001, the Institute of Medicine’s landmark report Crossing the Quality Chasm outlined 6 dimensions of quality care that the US health system should achieve: safety, effectiveness, efficiency, timeliness, patient-centeredness, and equity. A quarter century later, panelists, moderated by Stathis Antoniades, MPH, FABC, president of University Hospitals Cleveland Medical Center, acknowledged meaningful progress in some areas but also the work that remains, particularly in cancer care.

Alexa Simon Meara, MD, MS, associate professor at The Ohio State University Comprehensive Cancer Center, stated that treatment advances have outpaced the systems designed to support them. Innovations in cancer therapies such as immunotherapy and antibody-drug conjugates have significantly extended survival, but Meara noted that these patients who live longer now cycle through multiple subspecialists, often without the connective tissue of coordinated follow-up.

“Our current survival rates in cancer have outpaced our current system,” Meara said. “As we’ve siloed ourselves for billing, for insurance, for reimbursement, we’ve lost that connection—we are taking care of 1 person with multiple different ailments.”

Shilpa Gupta, MD, director of genitourinary medical oncology at Taussig Cancer Institute (Taussig) and coleader of the Genitourinary Oncology Program at Cleveland Clinic, pointed to prior authorization as one of the most concrete structural barriers to timely care. At her institution, a target of seeing new patients with cancer within 7 days is routinely met. However, starting treatment is another matter.

“If they can’t start their treatment because everything has to get denied at a knee-jerk reaction, and then we have to appeal, we are losing that whole idea of getting the patient started quickly,” Gupta said.

Kimberly Bell, RN, MBA, executive administrator of cancer services at Cleveland Clinic, spoke about personal accountability within health systems and described the proactive steps her teams take to keep patients in treatment, which included clinical notifications, financial navigators, and executive oversight of authorization gaps.

“Authorizations are a way to control costs. Sometimes that’s good, sometimes that’s bad. But we have tools that we can use. We will not stop treatment,” she said, describing a patient who had lost insurance coverage halfway through therapy. “If I have to write that drug off, I’m writing it off.”

Beyond insurance, panelists identified survivorship infrastructure and long-term data collection as underbuilt. Gupta noted that in some parts of the US, there is an oncologist desert, pointing to the need for hub-and-spoke models that bring cancer care closer to patients. Bell noted a looming workforce challenge she calls the “silver tsunami,” in which a rising tide of cancer survivors will overwhelm already strained primary care systems if oncology does not build the survivor-specific care pathways to support them.

The panel also called for institutions that are agnostic to a location to advocate for telehealth reform that would allow physicians to care for patients across state lines without the prohibitive costs and redundancies of multistate licensure.

White Bagging, PBM Reform, and Legislation Finally Catch Up to Cancer Pharmacy

Anthony Boyd, PharmD, BCPS, senior director of pharmacy, oncology and infusion services at Cleveland Clinic, moderated the session on oncology pharmacy to address the practical and legislative infrastructure that makes cancer treatment possible, as well as some common hurdles.

White bagging, a pharmaceutical distribution model in which payers carve out an infusion medication from the medical benefit and require it to be sourced and billed through an external pharmacy, was a hot topic of discussion, with the panelists noting that it fragments drug custody, complicates dose adjustments, and introduces safety risks that are difficult to manage. Mitchell Blewett, PharmD, MS, BCOP, BCPS, director of oncology pharmacy at Cleveland Clinic, said, “It’s like, ‘Wow, wouldn’t it be cheaper if I could just bring my own steak into a steakhouse and they just cooked it?’ Yes, theoretically, but it doesn’t take into account everything that goes into it. There’s so much more that goes into being able to safely treat a patient with cancer that the practice of white bagging really doesn’t take into consideration.”

Patricia Roberts, PharmD, MS, BCPS, BCSCP, director of pharmacy, oncology services at University Hospitals, described white bagging as particularly challenging for weight-based cancer drugs, where a patient’s dose may change between the time an external pharmacy compounds the medication and the time the patient arrives for treatment. Brooke Peters, PharmD, BCOP, associate director of pharmacy at American Oncology Network, described a policy against white bagging at her nationwide community oncology network, noting that payer pushback often results in medical-benefit exceptions.

However, legislative movement on the issue is gaining traction. Ohio’s House Bill 682 has focused on white bagging practices, and Florida’s Senate Bill 1550 was recently passed to outlaw white bagging in that state and restrict vertical integration by pharmacy benefit managers (PBMs). The panel viewed these as meaningful signals, even if the devil remains in the details of implementation.

Regarding technology, Roberts described her institution’s deployment of artificial intelligence (AI) tools in specialty pharmacy to accelerate prior authorization, automating straightforward approvals so that human pharmacists can focus on complex adjudications.

“If AI can maximize our time and respond to those things that can be acknowledged quickly and easily, that is a really big asset for our patients [with cancer] to get treated,” she said.

The session also addressed the growing complexity of biosimilar management, with panelists describing how institutional pharmacy departments are required to stock 4 to 10 biosimilars for a single reference product across a dozen or more oncology agents. The administrative and storage burden of that proliferation, the panel agreed, is substantial and ultimately detracts from patient care.

Why Moving Bispecifics to the Community Depends on More Than the Drug

Bispecific antibodies have transformed the treatment landscape for multiple myeloma and several lymphoma subtypes by offering patients effective targeted therapy without the logistical demands of chimeric antigen receptor (CAR) T-cell therapy. But moving these agents safely from academic medical centers into community and outpatient settings requires navigating a complex web of toxicity management, caregiver education, emergency department preparedness, and equitable access.

Beth Faiman, PhD, MSN, APN-BC, AOCN, TCTCN, FAAN, FAPO, adult nurse practitioner at Taussig, described the evolution at Cleveland Clinic from inpatient-only administration to a structured outpatient ramp-up protocol for myeloma bispecifics, including teclistamab and linvoseltamab. The protocol includes prophylactic tocilizumab on day 1, careful sequencing of step-up doses on weekdays to maximize available staff resources, telephone monitoring, and a mandatory care partner. She also notes emerging data suggesting that a 4-mg prophylactic dose of tocilizumab rather than the 8 mg extrapolated from the CAR T-cell therapy literature may reduce cytokine release syndrome (CRS) rates.¹

“So far we haven’t had anybody hospitalized,” Faiman said. “The patients are sleeping in their own beds, and once you get through that initial ramp-up week, the incidence of CRS is much lower.”

The panel also discussed the importance of greater knowledge within emergency departments about specific adverse effects or toxicities. Megan Vince, PharmD, BCOP, oncology clinical pharmacy specialist at Cleveland Clinic, highlighted a clinical decision support tool where any patient who receives a T-cell–engaging bispecific in the past 30 days and presents to an emergency department triggers an automatic alert for the treating physician, including a link to institutional care pathways for CRS and immune effector cell–associated neurotoxicity syndrome. She stressed that emergency physicians must be equipped to recognize and treat these toxicities, particularly as the drugs move into community settings where oncology expertise is less concentrated.

The session’s moderator, Alberto Montero, MD, clinical director of breast medical oncology at University Hospitals Seidman Cancer Center and chief medical officer of Quantify Specialty Care, a company developing home-based biologic administration, pointed to published data showing a disparity in bladder cancer outcomes between rural and urban populations following the approval of immune checkpoint inhibitors. The data show that urban centers see improved outcomes and rural areas fall further behind, highlighting the importance of equitable distribution.² The panelists agreed that expanding bispecific access will require proactive collaboration between academic medical centers and community oncologists, including referral frameworks that allow community providers to initiate therapy after training and then maintain patients locally once the ramp-up period has been completed.

Caregiver availability emerged as a critical and often underappreciated barrier. Patients receiving bispecific antibodies are typically in their 50s to 70s with significant prior treatment exposure, and the education burden is substantial. A layered education approach involving pharmacist, nurse, and provider visits was described as essential for minimizing confusion and improving adherence.

Closing the Biomarker Gap Before It Widens

Oncologists and oncology pharmacists discussed the state of biomarker-driven lung cancer care in the final panel moderated by Lukas Delasos, DO, assistant professor of medicine at Taussig. They discussed where the science has arrived, where the systems have not, and what is needed to close the gap.

Melinda Hsu, MD, medical oncologist at Case Western Reserve University and Seidman Cancer Center at University Hospitals, began by noting that lung cancer has long served as the unofficial poster child for precision oncology. What began 15 to 20 years ago with EGFR, ALK, and ROS1 testing now encompasses 10 to 12 FDA-approved biomarker-matched agents in the first- and second-line metastatic settings, with targeted therapies increasingly moving into earlier stages of disease.

Despite this progress, Delasos noted that up-front biomarker testing is still far below where it should be for advanced lung cancer cases. That gap, the panelists noted, is likely even wider for patients with earlier-stage disease, where the evidence base for biomarker-directed adjuvant and neoadjuvant therapy is more recent, and adoption has lagged.

Tiffany Chan, PharmD, BCOP, oncology clinical pharmacy specialist at Cleveland Clinic Foundation, described the operational complexity that precedes any new targeted therapy becoming available to patients. “It can be quite a disappointment for patients when something is new, and they’re seeing it on the news, so they’re looking at their results and seeing that they might be a candidate.... And then we’re telling them it just got FDA approved and it’s not necessarily something that’s available right now,” she said.

Tissue insufficiency remains a recurring challenge in obtaining comprehensive next-generation sequencing (NGS) results at initial biopsy, noted Emily Chheng, PharmD, BCOP, pharmacy clinical specialist at Cleveland Clinic. Reflexive ordering of circulating tumor DNA alongside tissue sampling, Delasos said, can reduce delays in beginning treatment while awaiting full molecular profiling. Regarding access, Chheng also highlighted the role of drug repository programs using donated medications from prior patients and manufacturer voucher programs as access tools for patients whose NGS results return while they are admitted with high tumor burden that requires urgent targeted therapy initiation.

The cost of these drugs must not be overlooked, Hsu emphasized. Even when insurance approves a targeted agent, patient co-pays can be prohibitive.

“The pace of new drug discovery is phenomenal, but the cost is just way too high. I have to explain to all my patients that even if insurance approves it, you probably aren’t going to afford the co-pay—and then we will still get this covered for you,” she said. “It’s an uncomfortable conversation that patients don’t want to have.”

The panel concluded with a discussion of AI’s emerging role in precision oncology, from digitized pathology predicting PD-L1 expression to AI-powered trial-matching platforms that could help oncologists identify clinical trial eligibility for patients with rare or nonactionable molecular alterations. Delasos closed by framing the current moment as the early innings of a longer evolution.

“We’re in our infancy of precision medicine and oncology in general,” he said. “Combining all these modern technologies, I think, is really going to lead us to the next era of precision medicine and oncology.”

References

1. Hamadeh IS, Merz M, Derkach A, et al. Low dose tocilizumab for mitigation of cytokine release syndrome with T-cell engaging bispecific antibodies. Clin Lymphoma Myeloma Leuk. Published online March 27, 2026. doi:10.1016/j.clml.2026.03.016
2. Al Armashi AR, Thierheimer M, Bukavina L, et al. Disparities in trends in bladder cancer mortality between urban and rural patients: a 2000-2020 analysis. J Clin Oncol. 2024;42(suppl 16):4583. doi:10.1200/JCO.2024.42.16_suppl.4583