Conference Coverage: ACCC

How Can We Identify the Value of Personalized Medicine in Cancer?

At Cancerscape, the Association of Community Cancer Center’s 42nd annual meeting on policy, value, and quality, held March 2-4, 2016, in Washington, DC, Kavita Patel, MD, MS, senior fellow at the Brookings Institution, spoke about the clinical imperatives of personalized medicine, with considerations for curbing healthcare costs and simultaneously demonstrating value to all stakeholders.

Patel posed the question: Can Value and Personalized Medicine in Cancer Care Co-Exist? “As a clinician, I always thought I was providing personalized medicine. So what has changed?”

Overall, Patel said, oncologists and physicians must start thinking about where they will position themselves in the new value-based payment models and value-based care. “Where can you insert value-based practices in your clinic?” she asked.

Drawing a simile with Tesla—a luxury vehicle that offers the promise of a reduced carbon footprint—Patel said that Tesla received tremendous subsidies from the federal government because of the value proposition the company presented for its expensive vehicle. “We need to come up with our own models and metrics, rather than have the government tell us what to do with respect to value,” Patel told the audience.

She said that as physicians try to prepare patients for the onslaught of costs coming from the therapies that are being developed, “we need alignment between what we are telling the various stakeholders, including physicians, payers, and patients.”

A few of the strategies that Patel proposed include:

• Targeting mechanisms that lead to cancer progression to improve outcomes
• These mechanisms are individual or personalized
• The goal should be to identify the mechanism of progression so we can specifically target it.

“Precision medicine boils down to taking each patient, identifying the best clinical evidence, identifying the molecular mechanisms, and then selecting the best algorithm that considers the longevity of treatment, screening, and follow-up,” Patel added. In her opinion, the ideal solution to improve outcomes with targeted therapies is to test the algorithm used [to develop the clinical trial] rather than the drug being used in the treatment.

How is value being defined today? Patel emphasized the utter lack of clarity around the term “value.” The definition often seems far removed from reality. “You cannot be held responsible for measures that do not make sense for the population you take care of!” Patel remarked.

“Patients trust us, we are their point person, and we are accountable for their health, not the hospital. This needs to be considered in these value-based models,” she stressed.

The Tightrope Act of Personalized Value in Cancer Care

Most of us, who are familiar with the oncology value models proposed by organizations like the American Society of Clinical Oncology,¹ the National Comprehensive Cancer Network,² and others, realize the myriad practical questions that these models create for those on the frontlines of cancer care delivery. Unless these frameworks are implemented in the clinic, questions regarding their utility will remain. However, implementing these tools may require educating not just the providers, but also patients and payers.

To discuss these and other challenges with transitioning to value-based care, the Association of Community Cancer Centers (ACCC) invited a panel of experts during its 42nd annual meeting on policy, value, and quality, in Washington, DC. The panel, moderated by Christian Downs, JD, MHA, executive director of ACCC, included Alan Balch, PhD, chief executive officer, Patient Advocate Foundation (PAF); Thomas A. Gallo, MS, executive director, Virginia Cancer Institute, Inc; and George Kovach, MD, Iowa Cancer Specialists.

Balch explained how their foundation functions. PAF, he said, provides patient support and guidance on patient access issues as well as financial problems that patients face pertaining their care. The National Patient Advocate Fund, he explained, is their policy and advocacy wing.

Circling back to the topic at hand, Balch said, “There’s need to standardize the frameworks to improve system efficacy.” There are 2 ways to approach this, he explained. “Decide the patient’s faith beforehand or discuss the options with them and personalize their journey through the disease.” Balch believes that an ideal provider—patient conversation should discuss goals of concordant care. “Over-standardization runs the risk of losing out on goal concordance and what is valuable for the patient,” he said. However, Balch feels that discussions around cost of care and affordability, which are so important for the patient, are the most difficult to handle. “I am not sure when the right time is to introduce that conversation, because it can stress the patient, but it needs to be done in a way that is meaningful to the patient.”

Gallo provided an operational perspective on this move to value-based care. “Physicians usually stay out of the conversation on finances because they are not comfortable with it. A lot of different frameworks and programs make it difficult operationally,” Gallo said. “We are still experimenting with the various options and trying to place programs in place to bring value. The burden is huge on the clinics because it takes time away from focusing on the patient.”

Balch added that the patient is faced with a lot of information all at once when it comes to a cancer diagnosis. They are overwhelmed since they are expected to understand and make decisions on a lot of clinical issues. Discussions on the financial aspects of care just add to the burden, Balch said, adding that “it should be a precision conversation.”

“Insurance has changed and out-of-pocket costs have risen significantly,” continued Gallo. “Further, the lack of oral parity creates additional burden. It’s bad enough that patients are worried about their diagnosis, and then over and above that they are required to have the conversation on financial matters.” He said that they have a very good team of financial counselors at the Virginia Cancer Institute that provides their patients the best information and guidance to navigate the journey.

Kovach, however, raised the issue of ‘insured but not covered.’ “A problem we have missed discussing is that many of these patients have insurance, but they are not necessarily covered for their required treatments.” Balch noted that not all patients would necessarily be interested or keen on understanding or discussing the cost of care. “The pace and scale at which they would want that information is what could be operationally difficult,” he said.

Kovach added that, as a physician, he tries his best to do everything on his end to insulate patients as much as he can around issues of cost and access. “I believe that physicians really need to be involved in this,” Kovach added. Gallo raised concerns with the rising administrative burden that oncologists face. “Most are already overburdened in the clinic. The fact that some of these frameworks have an information deficit just makes it that much harder,” he said. “If we can have a global approach for harmonizing the process, it’d definitely help,” Gallo continued. “Something like a common patient assistance form would ease matters so much more for us operationally. Standardizing would be a big help.”

References

1. Schnipper LE, Davidson NE, Wollins DS, et al. American Society of Clinical Oncology Statement: a conceptual framework to assess the value of cancer treatment options. J Clin Oncol. 2015;33(23):2563-2577. doi:10.1200/JCO.2015.61.6706.
2. Dangi-Garimella S. Another cancer drug pricing tool, this time from NCCN. The American Journal of Managed Care website. http://www.ajmc.com/newsroom/another-cancer-drug-pricing-tool-this-time-from-nccn. Published August 24, 2015. Accessed March 18 2016.

Expert Advises Physicians on What to Expect From Medicare in 2016

Speaking at the 42nd annual meeting of the Association of Community Cancer Centers, Cancerscape, held in Washington, DC, Lindsay Conway, MSEd, managing director, Advisory Board Company, brought the oncologists in the audience up to speed on Medicare’s reimbursement strategies for the coming year.

“Our team takes up strategic and operational issues that our members view as problematic and seek our advice on,” said Conway, adding that the issues could range from reimbursement to financing.

The following is an outline of the tips Conway provided:

• Drug payment will hold at average sales price (ASP) + 6% for 2016. However, this may not hold true for prescription drugs covered under the Medicare Part B program. CMS has announced plans to test a model with a lower add on payment for Part B drugs, which is expected to roll-out for testing by the end of the year.¹
• Biosimilars could potentially lower cost of care for Medicare, and the margin of payment would stay the same for providers, Conway said. Reimbursement would be ASP of biosimilar + 6% add on of reference product.

“Oncologists need to be aware that nearly 700 cancer-related biosimilars could hit the market in the near future,” Conway said, and there’s no escaping this new therapeutic option. She did agree that the current barrier seems to be physician awareness about a biosimilar product and their confidence with replacing the reference molecule with the biosimilar.

• While reimbursement is fixed for radiation therapy, overall, the more complex radiation therapy modalities are seeing a modest increase, while the less complex are seeing slight cuts in payments.
• Reimbursement for lung cancer screening has begun in 2016. This follows the release of coding and billing instructions by CMS in November 2015. “This means hospitals and clinics can find it financially sustainable to offer lung cancer screening,” Conway said.
• Hospital outpatient departments will be the testing grounds for new oncology-specific measures, Conway told the audience. This would fall under the umbrella of physician quality reporting system.
• Come 2017, patient-surveys would be widespread. While CMS is yet to finalize its decision on which survey would be used, Consumer Assessment of Healthcare Providers and Systems or CAHPS survey is being considered in the cancer realm. The CAHPS survey is an 85-question tool that includes 5 main domains: effective communication, shared decision making, patient self-management, access, and technical communication.
• Medicare Access and CHIP Reauthorization Act (MACRA) and physician payment stability. Following repeal of the sustainable growth rate (SGR) patchwork formula, a 0.5% annual increase in physician payment is expected through 2019. MACRA, the SGR replacement, helps hardwire risk-based payments for providers via 2 tracks: Merit-based incentive model system Advanced alternate payment models (APM)

“CMS still has to iron out the details, such as performance categories, provider payment, interchange between the 2 tracks, APM participant qualification criteria, etc.” added Conway.

She ended her review on a high note, speaking to CMS’ decision to reimburse providers for the time they spend on advance-care planning (ACP) discussions with their patients. “CMS has said that all primary care physicians and advanced practitioners should be eligible for ACP conversations with their patients,” Conway said.

Reference

1. Dangi-Garimella S. New payment model will test high-value prescription drug use under Part B. The American Journal of Managed Care website. http://www.ajmc.com/newsroom/new-payment-model-will-test-high-value-prescription-drug-use-under-part-b. Published March 8, 2016. Accessed March 18, 2016. EBO

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