Hope and Some Skepticism Whether Oncology Payment Models Will Work

Just over a week before CMS revealed some of its thinking on the future of oncology value-based care,1 oncologists and others who crowded into a Nashville, Tennessee, ballroom at the end of October shared their thoughts, successes, and frustrations regarding the current Oncology Care Model (OCM).

At certain points during the latest installment of the Institute for Value-Based Medicine®, an initiative of The American Journal of Managed Care^®, it was hard to tell if the physicians and healthcare executives were thinking about January 2020 or January 2021. Next month, oncology practices participating in the OCM must

decide whether to accept 2-sided risk. Come January 2021, CMS plans to start Oncology Care First (OCF), the successor to OCM; on November 1, it released a request for information (see Cover).

“It sounds scary, but I hope you leave tonight inspired, because I think we’re ahead of the game on this,” said Stephen M. Schleicher, MD, MBA, cochair of the meeting, an oncologist at Tennessee Oncology, and chair of the Quality and Value Committee of OneOncology, a network of community oncology practices. According to Schleicher, the oncology community should focus on 3 steps:

• Understanding the models in-depth because value-based care (VBC) is here to stay.

• Educating payers on how to improve their models to make sure that cost control does not come at the expense of patients.

• Optimizing care coordination to prevent avoidable emergency department (ED) visits and hospitalizations, facilitate end-of-life care planning, and avoid unnecessary tests and pharmaceutical use.

“Think before that PET [positron emission tomography] scan if you need it, think before that expensive drug, if we have a biosimilar instead,” he said, offering up examples.

Darin Gordon, who is widely credited with turning around TennCare, the state’s $10.5 billion Medicaid managed care program, described how it took him a few years to “lean into” the idea of VBC and value-based purchasing (VBP).

As part of his presentation, he reviewed a VBP framework, created by the Health Care Payment Learning & Action Network, which created a pathway for describing alternative payment models. The 4 classifications include category 1, fee for service (FFS); 2, FFS and a link to quality and value; 3, alternative payment models built on an FFS architecture; and 4, population-based payment.²

Gordon said that even after he “fully embraced” VBP, he had to again change his thinking. “I’ll just say this: As a self-diagnosed value-based purchasing zealot…where I literally thought we should buy light bulbs on a value-based purchasing agreement, after going through it, you discover there is a lot of stuff that valuebased

purchasing isn’t suited for.”

At the same time, he said, “there’s a big belief in the industry that we don’t arrive [to VBP] until we get everyone to category 4. I don’t think that’s right, either.”

Although the categories may seem like a continuum, with some organizations falling into category 2 or 3 because it works best for them, the only thing you won’t find, he said, is anyone defending FFS. There is plenty of evidence that FFS does not work, even if the evidence on VBP is not yet conclusive.

Instead, fueled by rising healthcare costs, there is an overwhelming sense from payers that “we have to try something different,” he said. Oncology is spread among all 4 categories—commercial, Medicare, Medicaid, and the exchanges.

In Tennessee, Gordon said he saw wide variability in cost from provider to provider, a diff erence of as much as 3 to 6 times that couldn’t be explained.

“We needed more tools to incentivize quality improvement,” he said. However, he said, he didn’t want to tell doctors what to do or how to do it: “I wanted to…create a dynamic [in which] the provider could start asking diff erent questions, should be asking diff erent questions.”

At the time, Vanderbilt University had a tool to connect patients to doctors via text. Although they didn’t get reimbursed for it, the institution was large enough to absorb the cost, according to Gordon. At that point, he said, he realized he could use the state’s Medicaid program to change reimbursement for physicians who had already told him, “We know what we need to do for patients, and we also know we won’t get paid for doing those things.”

“That was a big driving force for this,” he said.

Gordon addressed some advocacy groups’ concern that VBP agreements can be used to restrict access to certain treatments: “Actually, it’s just creating diff erent questions that the providers themselves—that clinician—[will] ask themselves in ensuring that they have the best possible outcome for that member.”

When VBP functions at its highest level—when payers, providers, and patients work together to improve health—he said, “quite frankly, a lot of discussions about prior authorizations are meaningless.” He added, “I don’t care as much, because you’re fully at risk.”

Although Gordon said he believes that VBP will remain firmly on landscape, Michael Kolodziej, MD, FACP, vice president and chief innovation offi cer at ADVI Health, was decidedly less upbeat. “I’m going to disagree with just about everything you just said,”he told Gordon, then said commercial payers look at oncology practices the same way Willie Sutton looked at banks: “That is where the money is.”

“How did we get into this mess?” Kolodziej asked. “The cost of taking care of cancer patients in the [United States] has exploded largely as a consequence of the cost of drugs that have brought great value for our patients but at a signifi cant price, and the rate of the trend so far exceeds the average person’s income that nearly everybody says [it is] unsustainable,” he said, launching into a review of the first alternative payment models in oncology.

When Kolodziej was in charge of oncology strategies at Aetna, he participated in the OCM when it launched. “As a care delivery model, the OCM is awesome, but Medicare did not go into this to improve the quality of cancer care. They went into this to save money,” he said. “The payment is based on this goofy methodology that they developed, and I think anybody who spent time thinking about this recognizes that the model is way too complicated, just way too complicated.”

So, after 4 performance periods, what have oncologists learned? There are problems with various parts of the model, Kolodziej said, which has been adjusted several times. Yet, even as savings increased, in his view, 90% of the participating oncology practices have no idea why they generated savings. “This model does not fix their pain,” he said, because it does not address the cost of drugs.

When he was at Aetna in a partnership with Texas Oncology, using the ClearPlus pathway saved 20% of the cost of care. He attributed that to the use of pathways, not Aetna’s medical home. He also challenged the notion that payers consist only of health insurance plans. The employers are the payers, he said, and they are complaining loudly to health plans.

“We have a long history [over the past] 20 years of paying too much for stuff that doesn’t work. We got some stuff now that works. That makes it really challenging,” he said, citing study findings that showed no link between the marginal added benefit of new drugs and the launch price.³

Referring back to the next iteration of the next oncology care model to come out of the Center for Medicare and Medicaid Innovation, Kolodziej was pessimistic: “I think that they cannot have a care model in which 85% of oncologists in the [United States] cannot participate, and that’s what OCM is right now.” Alternative payment models are not cutting it, he said.

Hearkening back to the idea of using new tools to drive improvement, Robert Daly, MD, MBA, of Memorial Sloan Kettering Cancer Center (MSKCC), explained how the center uses predictive data analytics to improve care for patients by meeting CMS quality measures for avoiding preventable hospitalization due to 9 conditions: neutropenia, fever, pain, dehydration, anemia, pneumonia, sepsis, nausea, and diarrhea.

With proactive care and increased communication, these can be managed in outpatients, he said.

Why is this an issue? Patients on active treatment have 1 hospital admission and 2 ED visits per year; about 50% of those ED visits and 40% of the admissions

are related to treatment toxicities, for 3 main reasons, Daly said:

• Patients are not being equipped to manage adverse eff ects at home.

• Patients assume little can be done to help them and don’t seek care until symptoms worsen.

• Communication varies between the patient and the clinician.

“As anyone who has treated cancer patients knows, they’re not just coming in with 1 symptom—they’re coming in with clusters of symptoms, “ Daly said.

Daly said the MSKCC pilot study was inspired by the work of Ethan Basch, MD, MSc, on the effect of patient-reported outcomes (PROs) on survival and quality of life. The 2017 study found that proactive self-management resulted in better outcomes for patients compared with standard of care, including a 30% improvement in quality of life, 7% fewer ED visits, and 5 months’ longer survival.⁴

The pilot project, called InSight Care, combines PROs with data and proactive care and case management to prevent hospitalizations and ED visits, keeping the patient “in sight” of the provider 24/7 through the use of digital technologies. Data analytics identifi es the highest-risk patients—the 25% of new antineoplastic patients

most at risk of arriving at MSKCC’s urgent care center. The risk model helps providers stratify patients to identify who is at high risk of a potentially preventable visit within the fi rst 6 months.

The model combines data from the electronic health record, including laboratory tests, home medications, comorbidities, and psychosocial data, to create a risk score. Doctors can add patients to the high-risk group using an override feature. In addition, Daly said, the interface that the patient sees is designed to lower barriers to patients’ completion of assessments. The questions have binary answers (yes or no), and the patient can give more details and use an avatar to provide a visual description of symptom location. The MSKCC staff can tell instantly tell if the alerts are mild, moderate, or severe. If necessary, the team can see the patient through a specialized video portal, instead of making the person drive into New York City from the suburbs.

As the pilot nears the 1-year mark, Daly said, the results show an eff ect, with a 59% reduction of high-risk patients visiting the urgent care center. Within the program’s first 30 days, there was a 60% adherence rate of completing assessments; for patients being treated for more than 3 months, a 50% adherence rate.

“That means we’re getting the symptom data from patients every other day on active treatment. That really helps to take better care of them,” Daly said.

Patients love the system, he said, because they know a member of the care team will get back to them within minutes. “They feel that they’re never alone, that there’s this team that is responding to them and helping to get them through their treatment. And they like the remote consultation,” Daly said. Oncologists like the system because they know that their patients are being taken care of while they are busy in the clinic, he added.

Some of the issues that have arisen include trust, Daly said. “This is an extension of the primary team working with the primary oncology teams to manage those symptoms,” he said. “How do we build trust with the primary oncology teams so that they feel those symptoms are being managed in a way that they would want them

to be managed?”

In addition, MSKCC initially hired clinicians with experience in palliative, supportive, and symptom care for the project, but as time went, it became clear that patients prefer someone with disease-specific experience.

Of note, when CMS held a listening session November 4 about the OCF model, officials announced that electronic PROs will be required to participate.References

1. Innovation Center. Public listening session: informal RFI on Oncology Care First model. CMS website. innovation.cms.gov/resources/oncology-listening-session.html. Updated November 14, 2019. Accessed November 20, 2019.

2. What is the Health Care Payment Learning & Action Network? Health Care Payment Learning and Action Network website. hcp-lan.org/.Accessed November 21, 2019.

3. Prasad V. Do cancer drugs improve survival or quality of life? BMJ. 2017;359:j4528. doi:10.1136/bmj.j4528.

4. Basch E, Deal AM, Dueck AC, et al. Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment. JAMA. 2017;318(2):187-198. doi: 10.1001/jama.2017.7156.

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