Bringing Innovation to Value-Based Care at Scale, With an Assist From Technology

What’s a little innovation among friends?

After a 2-year break due to the pandemic, the Institute of Value-Based Medicine ® (IVBM) brought health care leaders together on April 21 in Nashville, Tennessee, to discuss oncology care delivery—and to see colleagues in person, some for the first time since 2020.

The meeting, hosted by Tennessee Oncology’s chief medical officer Stephen M. Schleicher, MD, MBA, and Leah Owens, DNP, RN, executive director of Care Transformation, was part salon, part family reunion, as oncology providers from practices across the state gathered at the Hutton Hotel.

Schleicher welcomed presenters he described as friends, either from his residency at Brigham and Women’s Hospital in Boston, or from Nashville, now one of the hottest hubs of health care innovation and investment. After talks on new delivery concepts and lessons from the Oncology Care Model (OCM), Schleicher led a conversation with experts from the world of venture capital, which is providing the fuel for technology-driven solutions.

In recent years, the focus of delivery reform has been the OCM—which Tennessee Oncology mastered better than most.¹ But now, practices must shift to delivering the model’s best elements without extra funding from Medicare, as the OCM is set to lapse on June 30, 2022.²

“A lot has changed over the past 6 months,” Schleicher said. As support from CMS ebbs, he explained, commercial payers are looking at value-based contracts as a way to keep the OCM pieces that worked best. For some, venture capital offers a bridge to growth until payers can learn where these new solutions fit. Emerging companies offer “tech-enabled” tools, with which people provide the care while technology helps maximize resources, predict behavior, or speed decision-making.

Thyme Care: Navigation at Scale

Bobby Green, MD, was in oncology practice for more than 20 years—and with Flatiron Health for 7 years—before he cofounded Thyme Care with fellow Flatiron executive Robin Shah, MBA.3 As Green explained to the audience, ample evidence shows that cancer care navigation works and that digital delivery can improve survival. Results of a 2017 study led by Ethan Basch, MD, MSc, indicated that patients with advanced cancer gained 5 months of survival using an electronic system to log patient-reported outcomes.4 If a drug offered that much benefit, Green said, its use would spread quickly. But the Basch study and others have not brought navigation beyond some pockets of excellence.

“You have to ask the question, why?” Green said. “We know navigation works, and [yet] we know that it’s not widely available.”

The reasons for this, Green noted, are complicated. “Navigation is hard. And it’s expensive,” he said. It requires changing behavior, which involves more people and buy-in than prescribing a new therapy. Some practices have executed navigation poorly, and others haven’t tried.

For the past 6 years, the OCM made delivery reforms worthwhile. Green called the model “a framework in which incentives were actually aligned,” as practices took on changes including navigation or trying biosimilars. Overall, a major analysis commissioned by CMS showed that the model didn’t save much money.5 But as Green noted, the story was not the same everywhere.

“If you look around at pockets—and obviously one of those pockets is here in Nashville with Tennessee Oncology—there were practices that actually did really well in moving the needle,” Green pointed out, by keeping patients out of the emergency department (ED) and saving money.

The new challenge is scaling that success, and that’s where Thyme Care comes in. As Green said, the first step is building “a patient-centered care navigation platform. And the second is to work as an intermediary with the health plan and with practices to enable value-based contracts.”

While health plans provide the revenue (see Sidebar), Green said, Thyme Care forms partnerships with oncology practices, to understand their workflows, access electronic health records, and fully understand each patient. Primary care practices are part of the picture, too. Thyme Care makes heavy use of data—from claims, from prior authorizations, and from practices—that help greatly in connecting patients with services and high-value care.

Green shared pictures of the different types of reports that Thyme Care can generate, ranging from acuity scoring to prioritization of needs, documenting interventions and outcomes, and tracking a patient’s individual journey. “We think it’s really necessary to connect the dots and put people with the technology,” he said. “We call it technology-enabled navigation.”

Thyme Care, Green said, can “sit between the health plans and the clinicians to help design value-based contracts—and to help understand where the opportunity is.”

Using Nudges to Drive High-Value Care
Ravi Parikh, MD, MPP, an assistant professor of medical ethics and health policy and of medicine at the University of Pennsylvania’s Perelman School of Medicine in Philadelphia, turned the discussion to a longstanding problem in cancer care: what to do about low-value care. By some estimates, low-value care represents 30% of all cancer care spending, Parikh said, but measuring it, pinpointing it, and eliminating it are tough to do. High-profile efforts, such as the Choosing Wisely campaign, and Medicare’s crackdown on low-value care have had mixed results.

In the months before COVID-19 vaccines were available, the scenario that arose from the pandemic was one in which many experts thought low-value cancer care would be revealed: Providers and patients would weigh the risk of being in medical facility—and halting cancer’s progression—against the chances of contracting COVID-19.

But, as Parikh explained, it’s not that simple. “We could just decrease utilization across the board,” he said. “That might decrease low-value care, but it also might decrease some high-value cancer care.”

What is clear is that cancer screenings—considered a high-value practice—dropped as much as 50%, and some screening rates have not recovered. Thus, deciding how much low-value care is still happening just based on claims data is difficult, Parikh said, and he pays more attention to the trends that have emerged.

Instead, Parikh and his fellow researchers partnered with Anthem to study 5 specific metrics for non–guideline-directed care. He shared data showing that low-value cancer care was common before the pandemic, and with the exception of a specific radiation procedure, low-value care remained common after the pandemic began.

Low-value care tends to happen in certain practices; even when it declined, the numbers didn’t shrink much. What does this mean? Big drops in care during COVID-19 were likely due to less screening. “The fact that once patients made it into the clinic, things didn’t change all that much, is consistent with other evidence,” Parikh said.

What factors can propel change? Using artificial intelligence (AI) to predict low-value decisions—and perhaps head them off—is another area of study for Parikh’s group. His lab focuses on predictive analytics, using advanced algorithms to influence care delivery.

“A lot of this is hard,” Parikh said. Physicians may know they should encourage more palliative care and initiate end-of-life discussions with patients, but nudging them to do so takes work. Parikh’s lab used AI to trigger text message prompts to physicians if patients on that day’s schedule should have an advanced care planning discussion. The goal was to get oncologists to focus on their highest-risk patients and try for 6 talks a week. Physicians received a text message at the beginning of their clinic, and the results showed that the investigators were able to quadruple the rates of advanced care planning. “It persisted over the course of the 6 months after the intervention,” Parikh added. After adjusting for patient and clinician factors, they also found a 25% reduction of chemotherapy and checkpoint inhibitor therapy at end of life. Full data will be presented during the 2022 American Society of Clinical Oncology annual meeting.⁶

“Now, I don’t claim this to be the be-all and end-all solution to getting good end-of-life care,” Parikh said. “There are a lot of different amazing solutions, and solutions that are on the ground. But I think it’s an example of how we can merge analytics with behavior change to engender value-based cancer care.”

Home Hospital: Care Where Patients Want It
Elaine Goodman, MD, MBA, medical director of the walk-in unit at Massachusetts General Hospital in Boston and associate chief medical officer for Wellframe, started her talk by looking back at an incident with her own father, who at age 90 years has both asthma and metastatic prostate cancer. When Goodman and her husband (also a physician) were visiting him, he had a cough, dyspnea, and sinus pain, and his oxygen level was slightly below normal.

Based on past episodes, Goodman’s father knew he needed to take amoxicillin/clavulanate (Augmentin), but a trip to an urgent care office could end with him being admitted to the hospital, which he didn’t want. Also, his primary care physician would want to see him in person. So, Goodman signed her father up for a concierge service. The doctor saw him in a virtual appointment and 20 minutes later, he had a prescription.

With 2 doctors in the house to check vitals, Goodman’s father avoided a hospital stay. This is not the result for everyone. But Goodman believes that with help from technology, it could be—through home hospital.
“How do we deliver this at scale?” Goodman asked. “How do we make this the experience we can deliver for everybody—not just the people who happen to have a relative visiting with medical training?”

Hospital-at-home models have been successful, but Goodman explained that no models exist for scaling the service beyond a single institution and a few dozen patients. Staffing shortages will propel change, she predicted. “This is also where technology comes in, not to replace people, but to really extend their reach,” she said. Technology would also help “move more acute and high-level care outside of our institutions.”

Such a shift requires thinking about the patient—not the clinician—as the chief customer. The technology design will be no easy feat, Goodman said, because health systems must adopt equity as a key design principle from the start. Hospitals and health systems will need partnerships, because moving care into the home will demand help when hospitals move beyond their core competency. Finally, a technology investment only works with a parallel investment in people.

“Designing technology from the patient’s perspective is essential. Aside from it being the right thing to do, we need our patients to be engaging with these tools,” said Goodman. She declared that based on her experience with other startups, “the worst thing that can happen is that you buy this great tech tool, the patient gets it and then they put it in a drawer, or they use it for a day and then don’t use it anymore.”

Preparing the workforce for such a shift is as important as good design. Goodman has seen the resistance from providers when confronted with different technology solutions, such as declarations that “my patients don’t want this.”

Goodman said that an adage in the field proclaims that 20% of the success is about the right technology, and 80% is about everything else. “It’s the change management,” she declared. “When I talked about investing in people, it doesn’t necessarily mean more people….What it does mean is investing in hiring and training the next generation of people who are going to need to be technical workers.

“Don’t underestimate the amount of thought and resources that need to go into change management and supporting staff, especially right now,” Goodman concluded. “You think you’re putting enough communication out there and enough training, but especially in this moment, people are tired. And change is hard.”

OCM Lessons and the Path Forward
On paper, the OCM may not look like a financial winner, but it did spur practice transformation—and patients both inside and outside Medicare saw benefits, according to an official from the Center for Medicare & Medicaid Innovation (CMMI).

Hillary Cavanagh, MA, deputy director of the Division of Ambulatory Payment Models at CMMI, took part in the IVBM meeting remotely to give an overview of lessons learned from the OCM, which supporters say should not be judged solely on whether most practices saved Medicare money. Practices that became more proficient at operating under the OCM as time went on say that the decision to let it expire relied too narrowly on financial results accrued through only the first half of the model (see Cover). In doing so, they say, CMMI has failed to appreciate how much savings were achieved in some practices during the past 2 years. Tennessee Oncology, for example, released results that show $5 million in savings from the second half of 2019 and the first half of 2020.¹

In the OCM, practices are evaluated in 6-month blocks called performance periods; Cavanagh’s presentation included data produced by Abt Associates from the first 5 periods, although she noted the program will run for 11 periods.5 The early data, Cavanagh said, show that while Medicare did not see savings in low-risk episodes, it did create savings in the care of higher-risk patients. Through period 5, the net loss to Medicare was $377 million.

But CMMI evaluations have shown benefits, Cavanagh said. The scope of the OCM meant it reached a lot of patients: Almost 25% of the Medicare fee-for-service (FFS) chemotherapy-related cancer care fell under the model during the program’s life. This covered 126 practices, 7000 practitioners, 200,000 beneficiaries, and 260,000 episodes of care, according to the data presented. Five commercial payers took part alongside Medicare.

The CMMI evaluation team identified specific changes that led to higher-quality scores: (1) better and faster access to oncology staff, (2) patient navigation and coordination, (3) screening for pain, depression, and other needs, (4) patient education, and (5) expanding palliative care and culturally sensitive end-of-life care.

Most OCM practices extended delivery system reforms across all their patients, not just those in Medicare FFS; 40 of 47 practices evaluated by CMMI had done so. That meant commercial patients also experienced the benefit of navigation services, survivorship care, advanced care planning, and practice changes that kept patients out of the ED. Some large practices developed centralized navigation services that reached patients by phone.
“Many oncologists, nurses, and administrators [felt] that the high-quality care should be the same for every patient,” Cavanagh said. “We’ve heard different versions of this across the different practices that were visited: ‘If it’s good for Medicare patients, we should do it for everyone.’”

Although commercial payers did not like certain aspects of the OCM, care transformation has offered real benefits, and Cavanagh said she realizes that many oncologists want to know what will come next. “We are continuing to learn from the evaluation reports,” she said. But practices and payers are not waiting for CMMI to keep transformation going.

“Several practices told us that during contract negotiations with commercial and managed care plans, they successfully argued that Medicare funded additional investments with [Monthly Enhanced Oncology Services] payments, which benefited everyone,” Cavanagh said, and practices felt that payers should help sustain these services. 

References
1. Tennessee Oncology receives perfect quality score while saving Medicare $5 million during last year of Oncology Care Model. News release. Tennessee Oncology; November 20, 2021. Accessed May 20, 2022. https://bit.ly/3lAe7w0
2. Caffrey M. COA survey: practices find OCM a success; some added services may be at risk. Am J Manag Care. 2022;28(SP2):SP83.
3. Andreessen Horowitz leads $22M in funding for Thyme Care to improve patient outcomes, close gaps in health disparities and drive value-based cancer care. News release. BusinessWire; October 5, 2021. Accessed May 14, 2022. https://bwnews.pr/37JQXjE
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):197-198. doi:10.1001/jama.2017.7156
5. Abt Associates, The Lewin Group. Evaluation of the Oncology Care Model: Performance Periods 1-5. CMS. January 2021. Accessed November 16, 2021. https://innovation.cms.gov/data-and-reports/2021/ocm-evaluation-pp1-5
6. Parikh RB, Zhang Y, Small D, et al. Long-term effect of machine learning-triggered behavioral nudges on serious illness communication and end-of-life outcomes among patients with cancer: a randomized clinical trial. Presented at: American Society of Clinical Oncology Annual Meeting; Chicago, IL; June 3-7, 2022; abstr 109. https://meetinglibrary.asco.org/embargo/record/209350/abstract