FCS’ Walcker Explains Value-Based Cancer Care

Nathan H. Walcker, MBA, has been CEO of Florida Cancer Specialists & Research Institute (FCS) since August 2020, after joining the practice as chief financial officer in 2019. FCS was an early adopter of value-based care initiatives, and its physician, pharmacy, and business leaders have been active participants in the Oncology Care Model (OCM). That model ends today. As the practice readies its transition from the OCM, Walcker discussed what’s next.

This transcript has been edited for clarity.

Transcript

How would you explain value-based care to a new patient?

Value-based care at its core is rooted in a simplistic mathematical equation of value equaling benefit, or outcomes, over cost. But from this simplistic equation, many other questions follow: Value to whom? How is value measured? Cost to whom, and over what time period?

So, breaking that down further, I think value-based care is really about alignment. It’s making sure that the health care delivery system has the right incentives in place. That way, regardless of where your provider is practicing—whether it’s in the acute care setting, community setting, and across modalities/specialties—we are taking the time to actually get to know you [the patient] as a person and coordinating care across the entire value chain, [creating] the best experience and results possible so people can be healthier.

At the same time, value-based care means taking an opportunity to identify areas of improvement, reduction of waste, and making sure that’s it’s all about the patient.

What do you consider the most important elements of value-based care?

We at FCS have the privilege to serve patients and communities across the state. Our holistic approach to value-based care goes back to the proverbial Triple Aim in health care: that is, improving the patient experience, improving population health, and reducing cost. Coming out of the COVID-19 pandemic, we’ve now recognized that it’s also about our caretakers and our care teams—and making sure that we’re providing the opportunity to appreciate that patient experience is about the person, [but would not be possible without also prioritizing] everyone that’s taking care of that patient.

Ultimately, we care how all these things interact with one another in a holistic, coordinated fashion. Here’s an example: If 100% of the focus is on the reduction of costs, you have to believe that the patient experience probably won’t be great. Think about the last time that you were at a primary care clinic. I was at one with my 4-year-old daughter recently, and our primary care physician [PCP] spent about 8 minutes with us: I know because we counted.

That’s because of the clinic burden; the schedule is incentivized to see as many patients as possible and is a real pain point in the fee-for-service (volume) model we live in today. Now, that’s for a regular wellness check-up—think about how the patient experience would be if that same 8 minutes was with a patient battling cancer. You can see the point I’m trying to make.

So here at FCS, we’re making sure that these factors of value-based care are working together in a balanced fashion. We are bringing best-in-breed therapeutics into the marketplace, and we are harnessing the ability of tools, technology, and data to best inform the right treatment pathways in a cost-efficient manner at the right time. Something I’m very, very proud of at FCS is that we’ve taken a deliberate and intentional approach to bringing precision diagnostics in-house.

To me, the ability at diagnosis—or candidly, prior to diagnosis as the suspicion of disease—to learn the genetic, molecular makeup of a person, [to help] ensure that we are getting in front of disease progression, will bend the cost curve and hopefully stave off the higher-acuity setting downstream. Ultimately, the result will be better patient care.

At FCS, that’s what it’s all about—making sure that the Triple Aim, and now the Quadruple Aim, and other facets in health care act in unison with one another.

What are your priority metrics?

First, I’ll answer by listing the dimensions that we don’t value. In this world of information overload, “analysis paralysis” is the surest path to failure in anything—but especially in health care. We need to be in a situation in which no matter what program is being implemented—whether it’s the OCM, an alternative payment model [APM] with a commercial payer, even fee-for-service—[that we know] the metric that leads to the best outcome for the patient and also for the health care ecosystem at large. What delivers this from a cost-to-delivery perspective, and from a quality perspective, ultimately comes down to making sure that we are measuring at a macro level.

Second, how do we ensure that we are measuring and monitoring and also incentivizing the most cost-effective, clinically appropriate therapeutic for that particular patient? And ultimately, how do we measure that over time and follow that patient with a survivorship program? That’s why I’m excited about the advances that we’ve seen in precision diagnostics.

Today, we’re at a unique inflection point—not only in oncology, but in health care delivery [generally]. So much advancement in science and experiments coming out of CMS have changed the way that health care is delivered; we’re holding folks accountable to make sure that we’re not overutilizing care and we’re not overutilizing therapeutics. Nobody wants to be stuck with a needle one more time than they need to be, right? We’re making sure that we’re aligning all those things.

We take the vantage point at FCS that we need to be flexible, because the metric that matters today isn’t going to be the metric that matters tomorrow. But having a design infrastructure in which you trust the data that you have, you utilize them in an appropriate way, and they also drive meaningful change—not only for patients, but for the broader ecosystem of the company as well—is essential.

As we speak with oncologists and practice managers about the upcoming end of the OCM, we hear that the model cannot be turned off overnight. What will it mean for your practice when the OCM ends?

I wholeheartedly agree with that statement. This is like trying to try to turn a cruise ship on a dime—to go in the other direction at the snap of a finger is just not going to happen. We can all appreciate that behavior change, that transformation of anything that requires a long period of time, is a journey. It’s almost like a butterfly effect, where small incremental changes [occur] over time and you create meaningful change over a sustained period.

The analogy that I would use is to go back to everybody’s favorite technology system, the electronic medical record [EMR]. If you think about 10, 15, 20 years ago, the notion of using an electronically delivered system to monitor patient records and to use it to look at care packages was a foreign concept. But how did we get there? It took the HITECH Act in 2009, with which the government essentially incentivized providers to adopt the EMR.

Now, we can agree or disagree and have a really heated discussion on the merits of that government-sponsored initiative. But ultimately, I don’t think anybody can argue with the fact that over the past 10-plus years, there has been widespread adoption of technology and the office EMR—and certainly, some unintended consequences [have occurred].

Please don’t misunderstand me: [I do believe in part] that providers and expanded care teams are being data-entry clerks. That is something that must change in health care, and it’s necessary most of all in oncology. At the same time, that evolution of getting off paper systems has been transformative. It’s allowed us to have data and analytics and better monetary records, which again, from a macro perspective, have been really helpful. However, we certainly still need to do things.

Again, I go back to my PCP visit with my 4-year-old. We had to fax our records to the office. In 2022, the fact that this still happening is crazy. I mention this to shine a bright light on the fact that, absolutely, the OCM and our commitment to APMs are not things that happen overnight. It’s not a flip of a switch. But I will say that CMS and the [Center for Medicare and Medicaid Innovation] deserve a lot of credit for having the courage to try something.

Nothing in life is ever perfect, but we must continue to challenge the status quo of health care in America. The only way we can continue to improve is by taking some risks. I think the OCM from a very high level was very much a success. Depending on who you talk to, and what literature you read, there’s various schools of thought on this. But certainly, at FCS, we’ve seen tremendous benefits, not only for the practice, but also for our physicians and ultimately for patients. My hope and expectation is that it sets a foundation for many, many successful programs to come.