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Value-Based Care and APMs in Oncology: A Payer Perspective


Bhuvana Sagar, MD: To give an overview of the oncology models in the value-based world, there are several different approaches that different payers are taking on. Of course Medicare, who is the biggest payer, has come out with the Oncology Care Model (OCM). Several of us are participating in the OCM model. The OCM model is more of an episode-based approach. There are different episode-based approaches, and there are also bundle payment methodologies.

There are also several APMs (Alternative Payment Models) that are focusing on compliance with pathways, and there are some pathways that are more focused on just the medical oncology drug component. There are some pathways that, you know, look at the whole journey, from the diagnosis all the way to end stage. When is palliative care appropriate? When is a scan appropriate? You know this could be from initial diagnosis and, also, when they [patients] have completed their therapies.

So, episodes, in general, start with some sort of a trigger. It could be a chemotherapy trigger or a surgical trigger. They follow them [patients] along for 6 months. The majority of the episodes that I’m aware of are going on for about a 6-month period. They track the cost, in general. They also try to track quality to make sure that they get the appropriate care that they need and that there’s not underutilization.

Bundle payments, in general, are not applicable in the advanced stage as far as I’ve seen. They’re generally [utilized] in the earlier stage cancers where there’s a definite of treatment, and the period is also clearly defined—so maybe 4 months or a 6-month period where all the costs are accounted for, and there’s a comparison: Is there any cost savings when you’re doing it in the value-based world?

Now, pathway compliance—this probably would be more applicable not just to the bigger groups, but also to the smaller groups and individual practitioners to try to get a sense of how compliant they are with NCCN (National Comprehensive Cancer Network) guidelines. There are several pathways out there. A lot of the pathways are built off of NCCN guidelines. There are some pathways that are broader range pathways, and then there are some pathways that narrow it down a little bit more to if the outcomes are similar, can we pick the more affordable regimen? And there are pros and cons. It’s a very controversial area, I understand. But there are different ways of measuring value, overall.

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