Community Oncology Offers Nimbleness for Pivot to Value-Based Care

When the University of Washington released its first set of core quality data among the state’s oncology providers several years ago, the top performers were not the well-known academic centers certified by the National Cancer Institute.

Instead, the practice that stood apart was Northwest Medical Specialties, and soon the big institutions were calling on its medical director, Sibel Blau, MD, to learn how to deliver high quality care with her level of cost-effectiveness.

“Our medical home initiative started in 2013. By 2015, we had the first commercial payer initiative,” Blau said. That led to more recognition; today, her practice has pursued a joint venture with a hospital that helps that larger entity improve its contracting processes.

Payers benefit from this collaboration, she said, because no matter who is providing the care, it saves money if providers have value-based contracts and follow pathways. “It’s my practice that’s going to get the shared benefits,” Blau said.

Her story offered just one example of how community oncology practices can be laboratories for innovation in care delivery, during a session late Thursday at the 2023 Community Oncology Alliance (COA) Community Oncology Conference, held in Kissimmee, Florida. The session, “Thinking Outside the Box: Going Beyond the Traditional Model of the Community Oncology Practice,” allowed Blau and 3 other practice leaders to share how they continue to work on ways to deliver better care by offering just the right drugs or procedures, not the most.

Moderated by Stephen “Fred” Divers, MD, of Genesis Cancer & Blood Institute in Hot Springs, Arkansas, and the chief medical officer for the American Oncology Network, the panel also featured Alti Rahman, MBA, CSSBB, practice administrator for Oncology Consultants of Houston, Texas; and Brad Hively, CEO of The Oncology Institute, which has practices in 5 states.

The Oncology Institute offers physicians a national network to participate in value-based models, including those at full risk. Hively said making the shift to value-based reimbursement requires extreme care in contracting, because otherwise the practice is doing all the work to save money and the payer gets all the benefit.

“The average oncologist in this country writes between $8 million and $10 million in [chemotherapy] per year. Our average oncologist writes between $4 million and $5 million per year,” he said. “If you shift from volume to value without the appropriate reimbursement methodology, you crush your profitability. So, it’s a delicate balance.”

“Oncology risk is scary,” Hively said. The therapies are expensive, new ones are approved all the time, and it can be hard to predict which ones will dominate. A group such as TOI helps physicians by managing the risk and spreading it across a wider pool of patients. “We’re up to 1.8 million lives under capitation, and so we’re very well positioned to take that risk.”

“For smaller oncology groups that are thinking about taking on risk, volume is really important in terms of number of patients,” he continued. “So, we have to think about ways to come together and work together. That’s the name of the came in taking risk; you’ve got to be able to spread it over a large population.”

For Rahman, understanding the local market is key. “What does the overall health ecosystem look like?” he asked. Houston, where his practice operates, is the fourth-largest city, very diverse, and home to multiple payers—none of whom control more than 14% of the market. Managing multiple value-based contracts for various payers is difficult, but Rahman said it’s necessary. “If we’re going to work with payers, no one payer commands the population,” he said.

The proliferation of Medicare Advantage is a key development. Many academic centers refuse to accept this coverage, and community oncology can fill a void for these patients by learning to work with these plans, Rahman said.

“We're one of the very few practices in our county that takes the majority of those plans—that’s a barrier to access right there,” he said. “We don't have the marketing dollars that some of our very, very large institutions have, but at the end of the day, no amount of marketing dollars are going to matter if you walk when you call that institution and they say, ‘Well, you don't qualify to come here.’”

Divers said beyond the different contracts with different payers, “It's going to become more and more important in community oncology to champion that value proposition.” He asked fellow panelists to discuss the different components of making value-based care work, such as technology, data analytics, and staff buy in.

Rahman’s own journey with data analysis at Oncology Consultants began when his practice got bad news. In 2008, the director of contracting asked him to help find solutions after the practice had been deselected by Blue Cross Blue Shield. “At that time, there was no risk stratification, there was no kind of this emphasis on [hierarchical condition category] coding, or how do you look at staging, none of that was there,” he said. The insurer “simply deselected our practice, because our cost per cancer was too high, just per cancer.”

The more he worked with the numbers, the more Rahman realized that value-based care requires people like him—who love getting into the weeds to find areas for improvement—alongside physician and nursing leaders who can translate the numbers into what they mean for the lives of patients.

When Rahman joined his practice as an intern, he fully embraced the focus on data, but he acknowledges, “There’s no way that you can look at the complex methodologies around oncology actuarial studies, and [say], you know, what, ‘this is exciting.’ This is something I'm going to talk about at parties.”

It takes physicians and nurses to carry the message of what the data mean in terms of improving quality. Said Rahman, “You have to pair it with ‘what's the experience of the patient?’ And that's really where the magic happens.”

Blau agreed wholeheartedly. She also pointed to the value of being part of COA and the Quality Cancer Care Alliance (QCCA), a group of independent practices for whom she serves as CEO. The QCCA came together to support each other as the Oncology Care Model (OCM) took flight. Since then, Blau and other practices have also formed a research collaborative to help patients enroll in clinical trials.

“During the OCM we used artificial intelligence tools, we used different data analytic tools, but also our experience and experience from other groups. And this is one of the benefits of working within a network when we shared some data analytic tools. Those practices opened up their data—I didn't care if they saw that I did something wrong. Because what we learned from other practices and what they learned from us,” she said.

“This is an ongoing process,” Blau said. “It's not going to stay where we are today.”