Breaking New Ground in Episodes of Care, Including CAR T-Cell Therapy

Prospective payments in episodes of cancer care? Bundled payments in chimeric antigen receptor (CAR) T-cell therapy, at a fraction of the current cost?

Yes, it’s possible, said Edward J. Licitra, MD, PhD, CEO of Astera Cancer Care, the East Brunswick, New Jersey-based multisite practice that joined OneOncology in early 2021. During a session of the Institute of Value-Based Medicine® presented on November 3, 2022, with The American Journal of Managed Care®, Licitra highlighted groundbreaking oncology payment models with Horizon Blue Cross Blue Shield of New Jersey that promise to deliver on all of the elements of the quadruple aim: better care, reduced costs, improved patient experience, and greater satisfaction for physicians.

Licitra led a discussion with Joseph M. Pepek, MD, a radiation oncologist with Astera, and Joe O’Hara, MBA, a business consultant who until October was a director for Horizon Healthcare Innovations, an arm of the payer that develops innovative payment models. The 3 addressed a model for early stage breast cancer developed by Astera in collaboration with Horizon that covers the episode from initial diagnosis through intermediate care, including any surgical and postsurgical care, lab work, and radiology.¹

As Licitra explained, a single prospective price is paid for the entire episode, whether it lasts 6 months, 9 months, or 12 months. Astera provides treatments, radiation, surgery, follow-up, and home care. The model draws on Astera’s experience with the Oncology Care Model but is distinctly different, as that model offers shared savings months after the episode ends.

Receiving payment upfront puts the onus on the practice to appropriately manage the patient. “You essentially go at-risk,” Licitra said. “It’s kind of a form of mini-capitation,” based on a distinct population.

Why would a payer agree to this? O’Hara explained that the biggest advantage comes from locking in costs. From an actuarial standpoint, he said, both payer and practice can anticipate how many patients the practice will have with a given diagnosis over a given period, and estimate what the costs will be. Under most shared savings models, if you’re the payer, “you’re not necessarily locking in your costs, and you’re still carrying those outlier patients.”

The shift to prospective payments gives providers incentives to take actions that will drive down costs over time, O’Hara said. If successful:“The provider captures all the savings, and the payer gets the benefit of essentially eliminating those patients from a cost standpoint.” Reinsurance can be used to handle outliers (See Related Coverage).

When Astera approached Horizon with this concept, both sides had significant experience with value-based care, and Horizon had experience in episodes of care in 160 different clinical areas. The trend, O’Hara said, is that “the providers who are working in the episodes have significantly better outcomes than the providers who are not.”

It’s not fully understood why practices that participate in episodes of care programs report better outcomes, he said, but the data show that engaging in the models makes a difference. “Almost universally, the episode partners do better.”

Pepek said it made sense to him that this multidisciplinary breast cancer model would work in community oncology. The practice design is less fragmented than an academic center, and he said the communication is stronger.

He credited the relationships built with the Horizon team, and the common goal of keeping the patient at the center, “but at the same time helping to reduce some of the financial burden and the administrative burden—for both the patient and the practice.” It helps that Astera has a freestanding radiation center, with lower costs than might be seen in a hospital, he said.

Pioneering models in CAR T-cell therapy

Licitra finished the program with an overview of CAR T-cell therapy and Astera’s participation in a clinical trial involving Bristol Myers Squibb’s lisocabtagene maraleucel (liso-cel), sold as Breyanzi. The first CAR T-cell therapy was approved in 2017, and these treatments have since proved to be lifesaving for patients who have run out of options for certain lymphomas and leukemias, and more recently, for multiple myeloma. But the wonders of CAR T-cell therapies were offset by their practical and financial realities. The toxicity once made hospitalization a must, and the costs, which started at $373,000 just for the treatment, could run as high as $1.5 million per patient with hospitalization, Licitra said.

Over time, oncologists have learned more about managing those toxicities. And scientists have described liso-cel’s manufacturing process as one that results in a product with less toxicity than its predecessors for treating lymphoma.² “Since the side effect profile is much better, we can begin to think about different ways to administer CAR T cells,” Licitra said. “As we have more and more control over which CAR T cells we can use—which ones have a better side effect profile—and as we become more well-versed in terms of how to down-regulate the toxicity, should it arise, you can begin to see that maybe everybody doesn’t need to go to the hospital anymore.”

This shift is important and much anticipated, because in the past year CAR T-cell therapy has been approved in earlier lines of care. To broaden the reach of who can access CAR T-cell therapy, many believe that community oncology must administer treatments for fitter eligible patients.

“Now, if you make it even more interesting, CAR T cells are just the first of many cellular therapies that are going to be developed. So that’s why we talk about cellular therapies,” Licitra said. “There are 300 cellular therapies that are in development. Some are autologous CAR T cells; some are allogeneic CAR T cells, which are CAR T cells off the shelf; but there are NK [natural killer] cells; and there are tumor-infiltrating lymphocytes; and there are bispecific T-cell engaging antibodies. And then there’s CRISPR, gene-editing directed therapy….But all these amazing therapies are going to come with a very, very steep price tag.”

As Licitra thought through this problem, he said: “We’ve got to develop a different way of giving CAR T cells or expensive cellular therapies, so that every patient that needs one has the ability to get one—because what would be the worst thing that could happen is that we’ve got great therapies that cure people of cancer that are being moved into earlier lines of therapy, but patients can’t get access to them. Where they’re just so expensive, nobody wants to pay for them.”

Once Astera had taken part in the clinical trial with liso-cel, Licitra said the next question for Astera was: How do we take the next step? “How do we actually innovate from the perspective of reimbursement?”

“As you’ve heard, we’re all about episodes of care,” he continued. The next logical step would be to develop an episode of care model that could dramatically reduce the cost of CAR T-cell therapy administration and, in the process, prove to be a game changer with New Jersey’s largest payer, which has 3.8 million members.

Licitra said Astera was very close to completing a 6-month care episode with Horizon that he estimated would reduce costs by as much as 40%, depending on the pricing of CAR T-cell therapies in the market.

“So, from the time a patient was identified as being a candidate for CAR T-cell therapy, could we do everything that patient needed within a 6-month window?” Licitra asked. This would include determining a patient’s eligibility for CAR T cell therapy, contracting for apheresis, collecting the patient’s T cells, and sending them to the manufacturer for the engineering process, which takes 6 to 8 weeks.

“These are patients with advancing cancers, so we have to give them lymphocyte-depleting chemotherapy; infuse the CAR T cells in our office; monitor them for toxicity and, if they needed to be admitted to a hospital, make sure we have all that infrastructure in place with our partner hospital; then do all the scans for 3 months following the CAR T-cell [administration] to see if they have responded.”

Licitra said: “We have all the capabilities to do it. We have all the relationships to do it. Now it becomes, how do we do it? And how do we price it?”

There is great excitement about this possibility, he said, from partners that work with self-insured employers; they envision flying patients in from out of state and housing them in a nearby long-term stay hotel.

“This is all about collaboration and relationships and people coming together to create value disruptions in health care,” Licitra said. “Health care has really been dominated by people that have had tunnel vision. Nobody wants to work with anybody else, and will never be able to solve the big problems unless we’re all working together.”

References

1. Providing innovative cancer care—expanding episodes of care. Horizon Blue Cross Blue Shield New Jersey website. Accessed November 25, 2022. https://www.horizonblue.com/providers/news/feature-stories/providing-innovative-cancer-care-expanding-episodes-care

2. Caffrey M, and McNulty R. Tanya Siddiqi, MD, discusses the promise of reduced toxicity with liso-cel. The American Journal of Managed Care® website. November 24, 2020. Accessed November 26, 2022. https://www.ajmc.com/view/tanya-siddiqi-md-discusses-the-promise-of-reduced-toxicity-with-liso-cel