Experts Discuss Oncology Care and Payment Reform in Avalere Webinar

Oncology payment and delivery reform has seen plenty of discussion, especially in the wake of a pandemic that changed virtually everything about daily life, including the way physicians practice and patients’ attitudes toward seeking care.

The future of oncology care was the key topic of interest in a panel discussion held by Avalere Health on October 21, 2020. Avalere’s Sarah Butler, head of client solutions, marketing, and operations hosted the webinar, which featured a panel that included practice director Lance Grady; senior strategic advisor Roy Beveridge, MD; and Milena Sullivan, principal at Avalere.

Care delivery and payment reform are timely topics given the effect that the pandemic has had on cancer treatment. A study from Avalere and the Community Oncology Alliance (COA), published online just ahead of discussion, showed sharp declines in screenings and treatment in 2020 compared to 2019.

“It’s the screening, it’s the treatment, it’s the follow-up aftercare,” Beveridge said. “All facets of oncology care have been significantly impacted. And as you begin to look at the data, you realize this is going to impact us as a society for many years to come.”

The data showed that patient outcomes could be negatively affected by the trends, and Grady noted the implications that those data have when it comes to practicing oncology.

“From the business of oncology, this is also substantial,” Grady explained. “From a lack of predictability in fee-for-service (FFS) revenue this is significant, and from perhaps a lack of predictability if you are bearing risk in an alternative payment model with CMS or with a commercial health plan in that contractual arrangement, this also has ramifications.”

Beveridge also noted that the type of care for patients will shift as a lack of screenings leads to detection at later stages of disease, which will have a significant impact in the coming years.

Despite the negative effects stemming from the pandemic, the panelists agreed that a silver lining in the ordeal has been the significant growth in telehealth offerings and coverage.

“There were already environmental factors that were facilitating the adoption of telehealth, but with the pandemic and the flexibilities that the federal government and the states moved to put in place, we saw explosive growth,” Sullivan said. That is particularly true in the community oncology setting as opposed to hospital settings, she noted.

Even so, Sullivan stressed the importance of both monitoring the success of telehealth and seeing what still needs more facilitation or reimbursement incentives. That will help determine which of the flexibilities during the public health emergency should remain in the long term.

“When you talk to physicians and patients, they are much more accepting of telehealth than they were, say, back in January of this year,” Beveridge added. “I think that’s a very positive thing in terms of what this crisis has resulted in. People are much more comfortable with using technology when it’s available and accepting something that is good standard of care.”

While the government also moved to give patients the ability to use home health for physician-administered drugs, the complexity and safety issues involved with those products have slowed the shift to home health, according to Sullivan. Going forward, she expects different approaches will be taken depending on the therapeutic area and drug type when it comes to home health.

Beveridge agreed, noting that it is not as simple as providing drugs in the home. The drugs that oncology nurses administer are complicated and dangerous, requiring a certain skillset and a very controlled environment.

On the payment reform end, one obstacle when it comes to value-based models has been a disrupted baseline for setting risk-based payment or benchmark prices to enter into either downside risk or value-based contracts, Grady explained. But he thinks that value-based models are here to stay in oncology, depending on the practice setting.

“In [the Oncology Care Model], we’ve started to see that it is the small or mid-sized community oncologists that are outperforming or demonstrating characteristics of performance more so than health systems,” Grady said. That has to do with factors like patient flow and attribution, interventions, 24/7 care, and now telehealth. That and managing diagnosis to treatment are some key characteristics he cites for successful practices in value-based models.

Of note is also the upcoming implementation of the Radiation Oncology Model (RO) at the beginning of 2021. Sullivan sees it as a signal that the Center for Medicare and Medicaid Innovation wants to find ways to move more toward bundled, prospective payment models.

For his part, Grady hopes that physicians who see FFS revenue dropping do not jump to capitation just for a predictable salary.

“Just because you have a ceiling price doesn’t necessarily mean that ceiling-based medicine results in the appropriate care or the right sort of care that even a payer would like to see,” Grady said. He foresees CMMI implementing a combination of strategies when Oncology Care First (OCF) eventually launches. “They’ve given a FFS-based model in medical oncology, the OCM, toward a benchmark or set price. Now they’re looking at a fully prospective payment model in RO, and we’re likely to see a blend of the two in OCF.”

With innovations and advances in therapy, practitioners have made great strides in patient care. Beveridge considers precision, specialized medicine to be a key aspect of improvements in care. The understanding of genetics and biologics surrounding conditions has also improved.

“Now we have to understand our patients really clearly and understand the associated data to optimally treat these people based on really specific characterization of their tumors and the patient’s performance status,” Beveridge said.

Butler raised the issue of chimeric antigen receptor (CAR) T-cell therapies, products that have introduced complexities to the market when it comes to how to pay for treatment. Any durable, potentially curative therapies challenge the system, she explained, because the system is better set up to pay for treatments for chronic conditions and treatments that are not curative.

“We’ve got a long way to go to speed up the regulatory system and payment infrastructure to account for some of these innovations,” Grady said. Developing unique and innovative payment systems to match the innovations in treatment is necessary to make them available to the patients who can benefit from them, the panelists agree.

As far as policies and priorities with implications in oncology, the panel highlighted that another Trump administration would put focus on international reference pricing, a redesign of Medicare Part D benefit and reform rebates, and a ruling on the Affordable Care Act from the Supreme Court. A Biden administration, on the other hand, would focus on expanding eligibility for Medicare, direct Medicare negotiation, and a drug price review board.

The perfect storm of a pandemic and the resulting economic downturn has put Healthcare at the forefront of political campaigning ahead of the election, Sullivan noted, and much of the future of care is likely dependent on the outcome.