Florida Cancer Specialists’ Walcker: Taking a “Holistic” Approach to Value-Based 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 2019.¹ As CEO, Walcker describes his priorities in leading FCS’ 4200 employees as ensuring clinical care of the highest quality, with attention to innovative treatments; convenient access to clinical trials, including early-phase drug trials; and “delivering a relentless focus on operational, clinical, and financial excellence.”

FCS was an early adopter of value-based care initiatives. For nearly a decade, its physician, pharmacy, and business leaders have been active participants in the Oncology Care Model (OCM), and equally active in policy discussions at the state and national levels about the future of payment reform.^2,3 Today, as the practice readies its transition from the OCM, Walcker spoke with Evidence-Based Oncology™ (EBO) on what’s next for value-based care.
This interview has been edited for clarity.

EBO: We’ve heard the term “value-based care” for some time, but patients might not understand what it means. How would you explain the concept of value-based care to a new patient?

Walcker: 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.

EBO: At FCS, what do you consider the most important elements of value-based care?

Walcker: We at Florida Cancer Specialists 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 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 the 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,⁴ 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.

EBO: You mention the Triple Aim and balancing the various factors. What are your priority metrics? Should we be giving more priority to survival outcomes? To patient satisfaction scores? Savings? Reduced time in the hospital? What metrics do you value the most?

Walcker: 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.

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

Walcker: 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 2009,⁵ 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.

EBO: Practice leaders tell us, and studies also show, that the shift to value-based care requires buy-in—it requires champions at the top. What has been your experience of champions for value-based care at FCS?

Walcker: At FCS, we’ve been very proud the model that we’ve adopted and scaled across our 100 clinical sites across Florida. We haven’t trademarked it, but we’ve coined the term “regional accountability.” What that means is recognizing and appreciating that there’s both a global approach and a local approach, and it asks, “What is the change management that we will need to go from a macro perspective across FCS, but at the same time, give due credit to the fact that health care is local?” It recognizes that treating your patient in Tallahassee may be different than treating your patient in Naples, which could be a byproduct of different demographics in these markets, or different physicians, or other factors. We’ve adopted this regional accountability model, and we’re pinpointing champions in each specific market. Then, we’re aligning that to the broader company, by making sure that if we’re looking at something like the adoption of biosimilar [agents], we are asking, “How do we best effectuate and communicate the opportunity, but also still give credence and autonomy to the local position in that market, with respect to the disease mix, etc., that the physicians may be treating on a day-to-day basis?”

At the end of the day, physicians are competitive beings by nature. So, we have found that recognizing that regional accountability, being intentional, and coupling that with benchmarking and reporting has been very successful throughout our time in the OCM. It’s an approach—the physician scorecard—that we’ve adopted in many of our other alternate payment models with commercial partners as well. We are removing the ambiguity around someone’s performance and then showing them, based on a benchmark, how they are doing vs their peers. How are they doing vs the broader OCM program?

And importantly, where are their opportunities to improve? The issue could be communicating [information about] biosimilar adoption, offering care that is clinically appropriate, or even doing something as simple as engaging with our care management professionals in a different way, to make sure that our patients appreciate that they have the opportunity to pick up the phone and talk to an oncology-certified nurse 24/7/365. That’s really been among the silver linings with OCM—that we’ve taken the opportunity to be really intentional with investing in that regional accountability model. It has paid off for patients and for our physicians as well.

EBO: Going forward, what would you like to see a future CMS model look like?

Walcker: The best model starts with recognizing that no 2 practices are alike, just like no 2 people are alike. No 2 patients are alike—certainly not in oncology. So, I’d like to see a model that is flexible, one that allows practices to opt in and opt out of risk where they deem appropriate. Given the onslaught of risks and threats, candidly, that community oncology faces—whether from pharmacy benefit managers, drug pricing reform, or challenges to the traditional buy-and-bill model—many variables are at play that certainly call into question the ability for community oncology practices across the country to survive. Whatever model comes to fruition, the next evolution really needs to be meeting practices where they are and make sure that folks feel comfortable as they walk toward risk. If they’ll be moving to a model where they are not only providing opportunities for upside savings but electing to take downside risk, [they have to know that] they’re able to do so without finding themselves in a very precarious position.

At the end of the day, given the sticker prices and the inflation we’ve seen in drug prices [of late, we know] it can take only 1 or 2 bad events to potentially bankrupt the practice. Cancer care is too important for that to be a risk factor. The next evolution of the model needs to provide, again, the visibility and transparency for somebody to perform in an APM and know what the metrics are. How are they being reported? Are we making sure that whatever benchmark somebody is being managed to, or being asked to manage to, has been done in a transparent, fair way? An interesting thing we’ve seen at FCS—not only with OCM, but with other APMs that have been incubated with commercial payer—is that everyone has a different rubric or a different scorecard or quality metric. This makes it challenging for a community of like-minded stakeholders—payers, providers, and patients—aligned around the notion that we want to be delivering the care and the experience and outcomes consistently. You or someone you love receiving care would want to make sure that we’re balancing the financial incentives with the right clinical protocols and doing so in a fair and transparent manner.

References
1. Florida Cancer Specialists. Nathan Walcker, Chief Executive Officer. Accessed May 14, 2022. https://bit.ly/39nEu5v
2. Gordan L, Blazer M, Saundankar V, Kazzaz D, Weidner S, Eaddy M. Cost differential of immuno-oncology therapy delivered at community versus hospital clinics. Am J Manag Care. 2019;25(3):e66-e70.
3. Gordan L, Grogg A, Blazer M, Fortner B. Unintended consequences in cancer care delivery created by the Medicare Part B proposal: is the clinical rationale for the experiment flawed? J Oncol Pract. 2017;13(2):e139-e151. doi:10.1200/JOP.2016.016550
4. Shankar A. Why growth isn’t over for this best-in-breed biotech stock. Updated March 16, 2021. Accessed May 14, 2022. https://www.fool.com/investing/2021/03/13/why-the-growth-isnt-over-for-this-best-in-breed-bi/
5. HITECH Act of 2009, 42 USC sec 139w-4(0)(2) (February 2009), part 2, subtitle C, sec 13301, subtitle B, sec 3014: Competitive grants to States and Indian tribes for the development of loan programs to facilitate the widespread adoption of certified EHR technology.