AJMC® Convenes the First Gathering of the Institute for Value-Based Medicine to Share Best Practices in New Payment Models in Cancer Care
A generation ago, doctors made decisions, and everyone else adapted. The rise of patient-centered care has changed the game, making medicine a team effort, in which the physician collaborates with nurses, social workers, nutritionists, and other specialists. Most of all, physicians seek input from patients themselves.1 This is especially true in cancer care, where the advances have never been greater. And yet, as Lucio Gordan, MD, an oncologist with Florida Cancer Specialists, notes, the decline in cancer mortality over the past generation2 has come with a caveat: The cost of care is rising.
“Because of cost, because of concerns about access to care, we started to transition away from fee-for-service to value-based care,” said Gordan, who welcomed a group of care administrators and fellow physicians to a unique gathering in Orlando, Florida, at Rosen Shingle Creek on April 5, 2018. Advancing Quality in Oncology Care was the first session of the Institute for Value-Based Medicine (IVBM), a new initiative of The American Journal of Managed Care®. IVBM seeks to bring education on value-based medicine to regional locations by inviting thought leaders to share best practices across medicine, pharmacy, and management.
Representing those areas at the inaugural session were Gordan; Don Champlain, RN, MHA, associate director of Care Management for Florida Cancer Specialists; Aaron Lyss, MBA, director of Value-Based Medicine at Tennessee Oncology; and Chris Kepinski, PharmD, clinical oncology pharmacy manager for Southern Oncology Specialists, based in North Carolina.
As Gordan explained, therapeutic advances have come alongside a growing senior population; Census data show that when the first baby boomers turned 65 in 2011, they numbered 77 million.3 Cancer death rates have fallen 23% over 20 years,2 even among patients who have what Gordan called “bad cancers” like multiple myeloma. This means that “patients are staying alive and responding well to treatment,” he said, with much of this attributable to the rise of better therapies, including immunotherapies. Thus, cancer care costs, which reached $87.8 billion in the United States in 2014,4 are not simply derivative of pharmaceutical costs, Gordan said, but reflect that cancer is being diagnosed at earlier stages across a much larger population, one that is living longer with the disease. Quality of life is improved, too. “Patients are tolerating therapy better,” he said.
Value-based medicine seeks to target resources where they will do the most good, while avoiding unnecessary spending on the emergency department (ED), hospital admissions, or therapies that won’t work or that patients won’t take. Deployment of these principles requires communication and coordination among all the parts of the healthcare enterprise, the use of data-driven tools to guide decision making, and listening to the patient’s needs. “Everyone has to be engaged,” Gordan said.
New payment models must recognize a different way of doing business. As Gordan and Champlain would explain, Florida Cancer Specialists got a head start on the episode-based system that would become the CMS Oncology Care Model (OCM), which has now been embraced by 14 commercial payers and is in use by 187 practices.5 Gordan explained that OCM blends the concept of the patient-centered medical home with bundled payments; under the 5-year model, a triggering event creates an episode that runs for 6 months. Practices are paid $160 per member per month payments to provide care coordination and enhanced services, while achieving requirements that include 24/7 access to a clinician who uses a patient’s electronic health record. The OCM calls on practices to adhere to national clinical guidelines for use of therapies and, above all, to “adhere to a patient-centered approach,” Gordan said. “We can’t ever forget that.”
Opportunities and Barriers in Oral Chemotherapy
Kepinski followed with a presentation, “Best Practices: Treatment Planning and Management in Oral Therapies,” which highlighted the benefits of fully integrating the pharmacy into an oncology practice. While oral oncolytics can be convenient, they bring many challenges, too—which makes education essential, Kepinski said.
“Every year we know there are more and more oral chemotherapies coming out,” he said. “Drugs that are already approved have new indications,” perhaps with new dosing. Coordination with a patient’s primary care physician is essential to create a patient profile, which tells the pharmacist what other drugs the patient is taking. But avoiding drug interactions or allergies is just one element. Kepinski outlined the many steps that occur to make sure that patients can pay for their therapies, which may involve help from a foundation. The rise of high-deductible plans is complicating the math for patients with high out-of-pocket costs. “Foundations may cover the co-pay, but that might not count toward the deductible,” he said. “This is going to be a hot topic in the near future.”
The transition of some cancers from a short-term event to a chronic condition, requiring treatment for years, has given rise to the term “financial toxicity,”6 referring to the burdens that patients with cancer and their families face from the cost of care. Kepinski sees it up close. “Often, I get calls that have nothing to do with the medication,” he said. A patient who initially says that he or she can afford a drug “can do it for a month, but they can’t do it every month.”
Thus, follow-up is essential. Patients need phone calls at least once a month to ensure they are still taking oral medications, backed by lab reports and a discussion of any new side effects. Getting a count of remaining pills is a must, Kepinski said, and patients should be encouraged to bring up financial or insurance issues. Each phone call is an opportunity for education. “The back and forth helps involve the patient in their own care,” he said.
The Shift to Value Means Changing the Culture
In his presentation, “Culture Change and Process Improvement: Key Initiatives for Success in Value-based Payment,” Tennessee Oncology’s Lyss said that for all the unknowns about the move away from fee-for-service, this much is true:
“The old world is not coming back,” he said. Oncology practices must adapt to a value-based climate, and the only decision is how far along that practice wants to be.
In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act, or MACRA,7 giving physicians with any significant footprint in Medicare a choice of how they wanted to be paid: through the Merit-based Incentive Payment System or through an advanced alternative payment model (APM). The OCM gives practices the ability to meet advanced APM requirements, in a way that many commercial payers have also pursued.
Lyss said the OCM allowed Tennessee Oncology to build on lessons it had gained from earlier value-based initiatives. This was no “box-checking” exercise—this would call on the practice to improve its use of clinical pathways and its telephone triage system; a core feature of OCM is giving patients access to same-day appointments. Better access to palliative care and improvements in end-of-life discussions were musts. The shift to OCM required:
The best way to keep physicians on pathways is to report how much individual physicians adhere to them, Lyss said. So far, Tennessee Oncology’s adherence rate is about 80%. “Transparency keeps people on pathway,” he said.
Tennessee Oncology is seeing improved response times to phone calls. So far, there’s been a jump from 48% to 68% of symptom management calls being addressed within 2 hours, and improvement to 73% following the implementation of a case management system. Before the start of case management, 35% of calls to the triage nurse were not appropriate—that proportion has now shrunk to less than 1%.
A partnership with Aspire Health has embedded palliative care in the outpatient clinics, and claims data show a drop in overall spending, with more spending on hospice care and less on hospitalization in the last 6 months of life. “It’s one thing to operationalize it; it’s another to make it seamless,” Lyss said.
Educating patients is part of the picture, too. A team at Tennessee Oncology’s Chattanooga location took part in a quality training pilot with the American Society of Clinical Oncology to train patients to call the office first; this brought a 30% reduction in ED visits, and the program is now being implemented elsewhere.8
But Lyss said that the shift to value-based medicine isn’t just about putting in new processes—it requires a change of culture and takes clinician buy-in. Across 30 sites, there will be physicians at different ends of the spectrum: Some will be champions of change, and some will resist. “That’s one of the key strategies—we have to be sure we engage the early adopters,” he said. “They must have the respect of their colleagues in the office and help us operationalize this type of change.”
The Art and Science of Care Management
Value-based care has not achieved the uptake that experts and physicians themselves predicted back in 2015.9 Not so at Florida Cancer Specialists. Champlain and Gordan’s presentation, “Development of Care Management at Florida Cancer Specialists and Leveraging Data with Payers,” opened with this statistic: In 2015, only 0.51% of payments were value-based; in January 2018, 40.82% were. The OCM formally started later than other value-based models, but as Gordan explained, this 222-physician practice with 85 locations across Florida gets 51.84% of its payer revenue from Medicare, and ramped up early.
To achieve OCM requirements like 24/7 access and better care coordination, the practice turned to Champlain, who since 2015 has built a 75-person care management team of nurse navigators, nurse triage specialists, and others who coordinate services that range from nutrition to psychosocial care to survivorship, based on guidelines from the National Comprehensive Cancer Network.10
“From the time the patient leaves their visit until the next one, that’s care management,” Champlain said.
Care management starts even before the first visit to the oncologist. New patients are interviewed by phone before they come in, to review medical history and medications they are taking—while they can be retrieved from the cabinet. The central triage team handles calls all day, so that messages do not pile up at individual sites. Besides the incoming calls, care managers call out to check on patients. OCM requirements for a care plan are taken seriously. “It’s something we want them to use,” Champlain said.
Around-the-clock access is the key to keeping people out of the ED, he said. “A majority of the calls come later in the evening. Patients start thinking of things, and if you can’t talk to someone, that person is going to end up going to the [ED],” Champlain said. If a nurse can talk to the patient about side effects, or offer a solution to constipation, that trip is avoided. “The patients appreciate being able to reach someone at 2 in the morning.”
For Champlain, those who come for care—and their families—are not simply “patients.” They are “consumers” and “customers,” and he says they have the option to go elsewhere. He is proud of his team’s 96% customer satisfaction rating and the fact that he is saving payers money. “I have some of the best staff in the country,” he said. “We know we are making a difference.”
Gordan wrapped up the discussion with a review of how Florida Cancer Specialists has used data to hone in on where its hospitalization rates were high and for what types of cancer. Data allow a large practice to zero in on the practices or individual physicians who are outliers and identify cost-reduction strategies.
Payers are seeing results, he said. He shared results from 3 partnerships, including 2 unidentified payers (a third began in September 2017 and does not yet have results):
He hinted at the challenges ahead for large practices that are already efficient. For those practices that have already identified the “low-hanging fruit,” continuing to find major savings against an in-house benchmark will be difficult. “It’s very hard to repeat the same feat all the time,” he said.
Lyss agreed. CMS may have to look instead at practice spending relative to what is realistic for that market. “We need to talk about what is the sustainability, and a reasonable expectation going forward,” he said.