Headwinds and Whirlwinds: The Patient’s Journey in Value-Based Cancer Care

The term whirlwind captures the essence of value-based care—a phenomenon not exclusive to cancer treatment, but present in all health care domains. Although health care professionals grapple with this daily whirlwind, patients experience it differently, akin to an unexpected and formidable hurricane.

This term was used several times throughout the Institute for Value-Based Medicine® (IVBM) session on October 5, 2023, which The American Journal of Managed Care® presented in partnership with Rocky Mountain Cancer Centers (RMCC) in Denver, Colorado. Glenn Balasky, executive director of RMCC, introduced the word at the top of the meeting, recalling a high school friend’s struggle with prostate cancer and explaining how even highly educated individuals may not fully comprehend the medical procedures they undergo. Despite health care providers making data-driven treatment decisions and addressing patient emotions and adverse effects, he said, patients grapple with their version of the whirlwind, highlighting the critical need for effective communication and empathy in patient care.

In Sickness and in Health

“Do you remember that part of our wedding vows that included ‘for richer or for poorer, in sickness and in health, till death do us part?’”

“Yeah?”

“Well, they just called with my diagnosis. I have cancer. Happy anniversary.”

That was the first conversation Bill Cadman, president and CEO of the Schuck Initiatives, had with his wife on their 31st anniversary. Cadman, a former president of the Colorado State Senate, kicked off the IVBM event by giving the patient perspective on cancer care. He recounted receiving a diagnosis for metastatic squamous cell carcinoma in August 2022 after presenting with a lump in his neck—a symptom that had been treated as an infection for years before a proper cancer diagnosis. Then, the lump began to hurt. RMCC ran several weeks of tests to discover the cancer in 5 lymph nodes in his neck, and more tests were already scheduled.

This diagnosis was a stark reminder for Cadman of the impact of cancer on his family: His mother battled Hodgkin lymphoma as a teenager in the 1950s and had a treatment plan that was scheduled to last longer than her projected life expectancy. Although Cadman’s mother surpassed expectations and lived to see her 3 children graduate high school, she passed on, aged 42 years, after battling breast cancer and experiencing painful wounds following a double radical mastectomy. Cadman’s sister is a 3-time cancer survivor, having undergone a year and a half of chemotherapy.

Cadman’s journey can be divided into 2 phases. The first phase was marked by his initial encounters with the health care system, which he referred to as the “medical industrial machine” to depict the impersonal, detached nature of care that Cadman and his family experienced during his mother’s years of treatment.

“Phase 1 of my cancer journey was a whirlwind,” Cadman said. “And I’ve got to tell you, that medical industrial machine had already parked a really big chip on my shoulder. Really big. For most of my life and for a significant part of my childhood is where that chip had been growing.”

Although this phase was emotionally challenging for him—as it is for most patients after receiving a cancer diagnosis—it also led to his introduction to RMCC and the Penrose Pavilion radiology team, marking the beginning of the second phase of his cancer journey. During the second phase, Cadman said, his perspective on health care dramatically shifted due to his positive, personalized experience with RMCC. He praised the medical staff’s openness, engagement, and encouragement, noting that Timothy Murphy, MD, FACP, president of RMCC, provided reassurance, hope, and a sense of partnership that contrasted starkly with Cadman’s past experiences.

Cadman recalled Murphy saying, “We are taking this journey together.” When expressing gratitude for his care team, Cadman emphasized that the health care experience at RMCC was about people, not just processes and systems. “That massive chip that I was carrying for my entire life actually started to shrink the first day,” he said.

Cadman also quoted a caregiver who spoke of treating each patient as if they were a family member or friend, and he observed that this philosophy was evident in every interaction he had with the health care professionals at RMCC. His journey from despair and skepticism to trust and gratitude serves as a powerful testament to the transformative impact of value-based care and the compassionate, patient-centric approach Cadman said was provided by the dedicated health care professionals at RMCC. “Here I stand a year later, and because of you [Murphy], the cancer is gone from my neck and, also because of you, that chip is now gone from my shoulder,” Cadman closed.

Headwinds in Cancer Care

Costs across health care—especially oncology care—are rapidly rising in the United States, and the average cost for an individual health plan is skyrocketing, according to Lalan Wilfong, MD, senior vice president of payer and care transformation at The US Oncology Network. According to March 2020 data from CMS and the Peter G. Peterson Foundation, around 17% to 18% of the country’s gross domestic product spending went toward health care funding, and this figure is projected to reach 20% before 2030.¹

Beyond federal spending, costs are rising for patients and employers. Kaiser Family Foundation survey data from 2019 revealed a clear rise in patient out-of-pocket (OOP) costs and employer premium contributions in the past decade.² In 2009, the average annual patient OOP cost was $3515 and the average annual employer contribution was $9860, for a total of $13,375. These numbers jumped by 37% for patients and 26% in total in 2014, with average patient OOP costs of $4823, employer costs of $12,011, and total costs of $16,834.

Five years later, average annual costs increased another 25% to $6015 for patients’ OOP, and 22% to $20,576 for total costs, with employers paying an average of $14,561 per patient—and it is hard to ignore how health care spending during the COVID-19 pandemic may have affected these figures. “Not only are we as patients paying more for our health care, [but] our employers are paying more for health care, and that’s leading to less money to be used for other things, which are probably better spent than health care,” Wilfong said.

So why is it important to focus on oncology? Wilfong explained that oncology expenses are skyrocketing, surpassing other medical specialties in terms of cost escalation. The main driver of this surge is the ongoing development of new drugs. Although it is heartening that cancer outcomes have notably improved in the past decade, with patients enjoying longer lives, the financial burden has grown disproportionately. Having an aging population also contributes to a rising incidence of cancer, making it a more prevalent health concern. Notably, both commercial and government payers bear higher per-member-per-month costs for oncology compared with other disease areas. This situation is compounded by significant cost disparities among physicians, with no clear evidence that these variations result in improved patient outcomes.

What is noteworthy is the United States’ distinction as the most expensive health care system among developed nations. Although this is a widely recognized fact, US health care costs significantly outweigh those of other countries, with disproportionate improvements in health care outcomes.³

Wilfong first dove into the commercial health care market, which pertains to individuals younger than 65 years with nongovernment insurance. To him, it is interesting to observe that during the past year, based on a survey conducted by the Business Group on Health that represents a coalition of US employers focused on health care, cancer has become a primary topic of discussion among employers. Five years ago, it was not even on their radar. The reason behind this shift in focus is that 86% of employers now identify cancer as one of the top 3 cost drivers among all disease states for the commercial population younger than 65 years.⁴

One might logically expect employers to be more concerned about musculoskeletal diseases, given the physical demands of jobs like those at Walmart, where employees stack shelves and load shopping carts. Surprisingly, cancer has emerged as one of the costliest diseases in this demographic, even though its incidence remains relatively low, affecting only 1% to 2% of those younger than 65 years. Regardless, it consistently ranks among the top 3 most expensive medical conditions to treat.⁴ To mitigate these expenses and improve patient care, employers are taking various actions such as emphasizing navigation to higher-quality care facilities, increasing transparency in terms of cost and quality, and reducing inappropriate care. They are also moving toward value-based care and actively seeking centers of excellence for cancer treatment.

In the context of Medicare Advantage (MA), which provides coverage for those 65 years and older, the program’s popularity is growing due to plans that provide nontraditional benefits, such as vision, dental, or gym memberships, compared with original Medicare. In 2023, for the first time ever, more than half of all Medicare beneficiaries are covered by MA, and this number is projected to rise to 70% to 80% in the next 7 to 10 years.⁵ MA is inherently a risk-based model, motivating primary care physician (PCP) groups to accept risks and proactively manage patient care to reduce costly emergency department visits and provide better care. Additionally, primary care groups are increasingly taking on risks to align incentives and deliver higher-value care, and health plans are focusing on managing utilization and increasing the advanced services offered, along with seeking high-quality partners to provide better patient care. Finally, the presentation highlighted a significant shift toward value-based care in oncology, where various groups are engaging to deliver high-quality, high-value cancer care, moving away from traditional fee-for-service (FFS) models. This transformation underscores the need to manage patients’ cancer more effectively in the evolving health care landscape.

Physician Health Partners

Lisa Price, MD, chief medical officer and geriatrician at Physician Health Partners (PHP), shifted the conversation to PHP’s role in supporting PCPs and accountable care organizations (ACOs). Founded in the mid-1990s during the early days of value-based care, PHP was created to provide infrastructure and support for primary care practices lacking resources for effective care coordination, quality assurance, and utilization management. According to information presented at the session, it operates in 12 counties in Colorado and collaborates with more than 1800 PCPs across various health care contracts, including MA, Medicare Shared Savings, and commercial ACOs. PHP is also involved in Medicaid through regional accountable entities. In these regions, PHP collaborates with more than 230 primary care doctors, impacting more than 400,000 members, particularly those within Medicare. Further, PHPprime, an independent practice association (IPA), includes more than 70 practices with about 380 PCPs.⁶

According to Price, the partnership between PHP and PCPs is crucial for navigating the complexities of the current health care landscape and meeting quality metrics. Aside from IPAs lending a stronger voice to a practice working with health plans, hospital systems, or specialists, she also explained that a PCP can benefit from involvement with an IPA because this typically leads to access to better commercial FFS contracts and participation in shared savings.

“I would say that over the years, that piece has really been the lifeline to primary care practices,” Price said. “You really can’t survive in fee-for-service in primary care, so when I talk about wearing my hat asa PCP vs ACO, they’re very meshed nowadays, because people don’t really rely on that.”

Primary care is characterized by myriad quality metrics—with the National Committee for Quality Assurance HEDIS tool (Healthcare Effectiveness Data and Information Set) among the recognized standards—and PHP plays a pivotal role in helping practices excel in these areas. However, these metrics may not be as well defined in oncology, especially for PCPs who might not be as familiar with the specific quality measures in cancer care. With the additional challenge of dealing with 14 electronic health record platforms across various practices, PHP employs a data aggregator to streamline the information flow. Coaches are assigned to each practice to assist with process improvement, spanning areas like front desk procedures, quality metrics, and billing or coding concerns. Success is gauged through Medicare Star ratings, which is essential to maintaining a strong position in value-based contracts.

Communication between the PCP and the specialist is highly regarded. When considering the criteria for selecting an oncology specialist or any specialist through the eyes of a PCP, Price prioritizes several elements, including a commitment to providing high-quality care backed by expertise, evidence-based decision-making, access to research, personalized treatment plans, and—perhaps most crucially—effective communication with patients, families, and the PCP. The specialist’s ability to collaborate with the patient’s care team and ensure prompt access to treatment plays a vital role.

Price also emphasized the importance of cost considerations within the treatment plan, ensuring that patients can access and afford the recommended care. From an ACO standpoint, PHP and similar organizations strive to integrate value-based care into their primary care practices. Achieving success in value-based arrangements is now a necessity for primary care, given the limitations of FFS models. In this context, Price highlighted several key factors such as affordability, alignment with specialist teams, the patient experience, timely access, and the specialist’s capacity to work within the peer team.

ACOs aim to form strong partnerships and transparent relationships with payers to drive better outcomes and cost-effectiveness. These arrangements vary from care coordination fees to shared savings models and risk arrangements. Although complex, these partnerships rely on trust, respect, and open communication, and they seek to manage costs efficiently in a health care environment characterized by the skyrocketing expenses of specialized medications. Price also underscored the importance of tight relationships with specialty partners, mutual respect, and efficient communication, especially in cases involving prior authorizations.

“For any of these kinds of value-based arrangements, you’re going to need to have strong partners,” Price emphasized. “You’re going to need to be aligned to try and get the best care for those patients and the best outcomes in a way that they like and they’re satisfied [with], and you’re ultimately going to control costs, because that’s what we’re all paying for.”

ACOs and Practice Culture

Mike Tyson’s famous quote, “Everyone has a plan until they get punched in the mouth,” was used to kick off the portion of this IVBM focusing on the complexities of delivering high-quality cancer care within an ACO. “Here’s the thing: No matter what, things are going to come up,” said Leslie Busby, MD, MBA, chair of the pharmacy and therapeutics committee at RMCC and The US Oncology Network. “There are going to be whirlwinds, there are going to be problems, there are going to be issues. It is culture that helps keep things from falling apart.”

Culture is identified as a pivotal element when it comes to patient-centered care, and physicians within the practice approach patient care with varying perspectives. Some focus on research, aiming to include as many patients in research programs as possible, whereas others are keen on adopting cutting-edge treatments. Specialization in certain fields also plays a role. Balancing these aspects is crucial when cultivating a culture of value-based care. In building and maintaining the right culture and supporting physicians in the best way possible at RMCC, their ACO clinical model becomes a critical aspect. It ensures that patients receive the highest quality of care while addressing individual patient needs, especially prioritizing low costs balanced with high treatment quality. Care pathways are brought into focus through this model, highlighting the importance of evidence-based or value-based care. In discussing this, Busby underlined the significance of pathways in guiding treatments, comparing pathways based on National Comprehensive Cancer Network (NCCN) and other guidelines, and noting that this structured approach helps in monitoring metrics such as pathway adherence and rates of hospital admissions and emergency department visits.

Technology plays a major role in ensuring that health care providers have the information they need at the point of care. With this in mind, RMCC utilizes the Clear Value Plus support tool, which compiles a wealth of patient-specific information such as diagnosis stage and relevant factors like genetic mutations. This platform offers comprehensive insights into treatment regimens, their alignment with NCCN guidelines, and whether they conform to The US Oncology Network’s Value Pathways. It also provides data regarding the incidence of febrile neutropenia and the frequency of associated adverse effects like vomiting. When physicians place orders, this system equips them with a wealth of pertinent information. The software also features links that enable health care providers to delve into the rationale behind a regimen’s inclusion or, notably, its omission from the pathways, making these data readily accessible to doctors for their decision-making process.

Busby emphasized several crucial aspects of cancer care management, with one key element being therapeutic interchange, an intricate challenge given the ever-evolving landscape of treatment options. For instance, the emergence of biosimilars has complicated matters, with different payers supporting distinct biosimilars for the same reference therapy. To relieve physicians of this complexity, the pharmacy team plays a vital role by seamlessly switching between biosimilars based on the payer’s preferences. Further, pharmacists meticulously review intravenous and oral medications, scrutinizing not only the drugs but also their doses and potential interactions. This meticulous clinical review proves invaluable in ensuring patient safety and optimal treatment outcomes.

Busby also highlighted the importance of precision dosing in the context of biologic agents with wide therapeutic windows. By implementing dose banding according to patient weight, the medical center has successfully reduced drug wastage and achieved significant cost savings. However, he acknowledged the challenges posed by the rapidly expanding field of biosimilars, expressing concerns about manufacturers withdrawing from the market due to excessively low pricing. In response, efforts are under way to maintain clinical effectiveness while controlling costs, such as examining the need for white cell growth factor support and exploring cost-effective alternatives for cancer treatment in the bones.

Busby further emphasized the integral role of pharmacists in monitoring and facilitating these cost-effective transitions, working closely with health care providers to optimize patient care and treatment affordability. In the realm of care transformation, Busby underscored the multifaceted journey patients undertake, requiring buy-in from the entire health care practice. Every aspect, from financial counseling and education to survivorship support, plays a crucial role.

“It’s got to be a buy-in of the whole practice in this, because everybody is touching these patients all the way along,” Busby emphasized. “And all of them maybe individually don’t see much like nutritional screening.… We know that when patients are malnourished, they don’t recover as well, they don’t feel as well, they don’t do as well. So, if we can maintain their nutrition, that may keep them out of the hospital.”

Additionally, RMCC has implemented measures like open slots for acute patient visits and around-the-clock physician availability to intervene early and prevent unnecessary emergency department visits. Busby envisions a promising future for cancer care management with advanced possibilities such as centralized nurse triage available 24/7. He anticipates the integration of patient reporting outcomes, possibly enhanced by artificial intelligence (AI), offering patients an interactive platform to assess their well-being, seek guidance, and alert clinics to potential issues, ultimately improving the patient experience and care delivery.

When it comes to the implementation of AI in health care, Busby acknowledged that RMCC is still in the early stages of exploring its potential, but the practice is interested by many AI products available, such as one by an oral oncology group focusing on up-front prediction to identify patients at risk of facing difficulties during their treatment journey. This AI tool assists in setting up more personalized touchpoints for these patients at high risk, hopefully leading to early interventions. There is also growing interest in the concept of concurrent prediction, where AI can detect subtle signs of a patient’s deteriorating condition during treatment, offering the potential for timely, proactive interventions. Although this remains a forward-looking endeavor, it is considered an exciting area of exploration.

Social Determinants of Health: They Affect Everyone

Robyn Tibert, MDIV, MSW, LCSW, OSW-C, social worker at RMCC, delved into the multifaceted realm of social determinants of health (SDOH) and their profound impact on managing the social and psychological aspects of cancer. With an emphasis on recognizing the significance of these determinants, Tibert began by sharing a poignant story about a patient called Wendy. As a mother aged 40 years with 3 children, Wendy found herself in a challenging situation. Balancing a job in a customer service call center, raising her children, and grappling with limited finances, Wendy was thrust into an entirely different world when diagnosed with stage IV triple-negative breast cancer. Her life was suddenly characterized by questions, fear, and practical concerns, as she pondered the impact on her family’s financial stability and health insurance. This narrative highlights the immediate and lasting impact of SDOH on individuals battling cancer. “A large and growing body of evidence suggests that these social resources like financial security, health insurance, [and] social connections significantly impact health care outcomes,” Tibert said.

Tibert expanded on the concept of SDOH, categorizing them into 5 domains: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context. She dispelled the misconception that SDOH are exclusive to particular demographic groups, emphasizing that they affect everyone. From the positive influence of a quality education, access to safe neighborhoods, a steady income, and supportive social connections on health outcomes to the negative effects of financial instability, environmental pollution, and social isolation, these determinants are a powerful backdrop shaping health.

Economic stability is one of the most immediately recognizable factors. Patients who struggle with stability in this area often find themselves choosing between vital treatments and basic necessities, and the financial burden imposed by cancer treatment can be overwhelming. Tibert then covered education access and quality, underscoring the influence of education on health literacy, understanding treatment options, and decision-making, and emphasizing the role of visual aids in facilitating comprehension and empowerment. Regarding health care access and quality, factors such as health insurance, transportation, and telehealth can make the difference between consistent medical treatment and lapses that could jeopardize a patient’s health.

Another main point surrounding built environment and neighborhood safety demonstrated how individuals living in unsafe neighborhoods or exposed to environmental hazards may face significant health challenges. This domain underscores the importance of addressing environmental barriers, whether through safe transportation options, meal delivery services, or telehealth offerings. Finally, Tibert explored the domain of social and community context, emphasizing the impact of relationships on health. A strong social network can provide emotional and practical support, making the cancer journey more bearable.

To conclude, Tibert emphasized that medical care alone is insufficient for improving health outcomes. SDOH play a substantial role, with medical care accounting for only 10% to 20% of health outcomes whereas SDOH contribute to the remaining 80% to 90%.

“We must listen to our patients to understand the barriers they’re facing,” Tibert concluded. “Let’s also listen to their strengths to see what’s going right, so we can help build on those strengths. If our shared goal is to improve health outcomes, we must have a commitment to understanding and addressing social determinants of health.”

Recognizing and Overcoming Headwinds

To conclude the event, Murphy, the RMCC president, asked Price, Busby, and Tibert about the headwinds and challenges each has experienced in daily practice. When asked about the importance of patient experience and shared decision-making in successful ACO or value-based care arrangements, Price expressed that the focus has always been on delivering high-value, cost-effective care that aligns with patient preferences. Further, she emphasized the idea that health care can be seen as a retail experience, acknowledging the importance of patient satisfaction and engagement. For health care providers, the initial motivation to enter the field was to provide excellent patient care, making patient experience a central aspect of their practice.

She also delved into the significance of compliance metrics and quality measures in health care, raising the question of whether 100% adherence is realistic and noting that there is often variation in patient behavior and adherence. She also shared a real-world example related to medication errors, illustrating that the root causes of nonadherence extend beyond the patient. It is revealed that health care providers’ practices and behaviors can also contribute to medication nonadherence, highlighting the need for introspection and adjustment in health care delivery.

Busby then reflected on the changes at RMCC as the practice shifted away from FFS and toward a more value-based care model. He acknowledged that there was some initial skepticism, but the shift gained traction as shared savings became a tangible outcome. Time and persistence played a significant role in the transformation, as the emphasis on value-based care became a recurrent theme, and the support of the leadership team and the receptiveness of younger physicians facilitated the transition, with some older physicians facing a learning curve due to their extensive experience with FFS models. Overall, the gradual shift and evolving understanding of value-based care principles have contributed to the practice’s transformation.

Finally, Tibert highlighted more initiatives aimed at further integrating the consideration of SDOH into patient care, highlighting RMCC’s recent implementation of the NCCN Distress Thermometer, which includes a problem list designed to inquire about various SDOH.⁷ This tool is expected to enhance the social worker’s ability to identify and address the challenges patients face early in their treatment journey, thus improving the overall patient experience. “You can see why I feel blessed getting up and going to work every day with the people I’ve worked with,” Murphy said. 

REFERENCES

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