How Oncology and Primary Care Convene to Deliver Value-Based Medicine

Primary care providers and oncologists play distinct roles in a patient’s cancer care journey, and both are crucial to ensuring that cancer is managed in a way that factors in current best practices while considering each patient’s individual care goals. Collaboration between primary care and oncology is also key in the goal of value-based care—delivering the best possible care in a space where costs continue to rise and financial toxicity impacts both patients and the health care system.

Experts convened in Tucson, Arizona, for an Institute for Value-Based Medicine event, presented by The American Journal of Managed Care and Arizona Oncology, that centered on collaborative efforts to improve patient experience amid the ever-increasing cost of oncology care. The theme, “Together: A Better Way to Fight Cancer,” reflected the roster of oncologists, primary care physicians, and program directors who took part in presentations and a panel discussion to share their expertise and consider novel ways to enhance cancer care.

A Collaborative Approach to Cancer Care

Joseph Buscema, MD, physician chair of the managed care committee and past president at Arizona Oncology, served as event chair and started the evening with a discussion of the cost of care for patients, which has been driven largely by the advent of novel therapies and their hefty price tags. “The problem is that as these drugs are developed, they have exorbitant costs, and much of the technology that we have embraced has certainly dwarfed the diagnostics that we had years ago,” Buscema said. “So, the imperative is how do we, as the prescribers and caretakers of patients in this model, and the payers come together? And it is imperative that we do. I don’t see it as a conflict or opposed situation, but one where we have to figure out how to get on the same page.”

The roots of rising costs in oncology are multifaceted, he said, with the largest component of drug development costs being research and development from preclinical research to postmarketing studies. Even the cost of failed drug candidates has an impact on the overall cost of successful development.

But through a value-based care lens, the high prices of the latest therapies must be balanced with cost-saving measures—while improving outcomes for patients. Many facets of care contribute to this goal, from shared decision-making with patients to cancer prevention and early detection, as well as efficient care coordination between providers. Along the way, measuring treatment outcomes and closely managing costs are pillars of value-based care execution.

Together, Buscema explained, oncologists and primary care providers can seek efficiencies in the treatment of patients as the oncology space embraces the less toxic, more effective therapies that have become available for many patients. Timely access to care and fiscal restraint, when possible, are also key aspects in optimizing treatment for patients.

Oncology and Primary Care: Closing Gaps in Collaboration

Synchrony between primary care providers and oncologists is increasingly important for several reasons, Thomas J. Biuso, MD, MBA, associate clinical professor of medicine at the University of Arizona College of Medicine and New York Medical College, explained at the start of his presentation, “Oncology Care and Primary Care: A Collaborative Approach.”

The cost of care is already astronomical, and with the number of cancer survivors increasing—in part due to novel therapeutics and diagnostics—the population of older adults with chronic conditions is also expected to rise, Biuso said. From the payer perspective, this trend means that not only are the costs of oncology care rising, but the cost of nononcologic conditions among survivors also warrants consideration. Value-minded payment models such as the Enhancing Oncology Model (EOM) from the Center for Medicare and Medicaid Innovation consider total costs of care, not solely oncology spending.

Biuso highlighted a meta-analysis published in CA: A Cancer Journal for Clinicians, the official journal of the American Cancer Society, that focused on the primary care provider and cancer specialist relationship, noting key findings that tie into the theme of a need for efficient collaboration between them.¹ “Many cancer specialists around the country just endorsed a specialist model—they don’t want primary care in the mix. Primary care physicians, on the other hand, believe that they play an important role in the cancer care continuum,” he said. “There was a lack of survivorship communication—that’s a key finding. And then, there are discrepancies between primary care physicians and oncologists regarding the goals and expectations.”

Taking it further, Biuso surmised that some of the barriers to higher-quality care and collaboration are the fragmented system in which providers work, a history of inadequate reimbursement, a lacking workforce for survivorship care, and the scarcity of clinically integrated networks in the United States. Consolidation also has been an increasingly prominent trend in health care that has contributed to a shortage of care access points and physicians. Finally, there is usually no formal agreement on who plays what role in the primary care and oncology collaboration. In addition to those barriers, Biuso noted the increasing pressure for primary care to take on more risk—a trend also seen in oncology with models such as the EOM.

“Medicare [efforts] are front and center, they want to transform care. And they are interested in care redesign and financial accountability,” Biuso said. There have been numerous Medicare initiatives to transform care with varying levels of success, focusing on care coordination, optimizing the treatment of complex patients. Because these initiatives are not mandatory, there is often not enough volume for initiatives to be successful for cost saving.

Still, there is no consensus on the best collaborative care model to optimize the relationship between primary care and oncology. Regardless of the current or future value-based care initiatives for primary care or oncology, the most crucial part for practices and oncologists is understanding exactly what value-based agreements will measure to determine success.

“You need to understand the agreement lock, stock, and barrel,” Biuso said. “You need to understand what you are signing, the contract risk, you need to understand how your performance is being measured, and you need to understand the insurance risk. And any risk agreement that you go into should have agreed-upon quality outcomes, spending outcomes, and utilization outcomes.”

Why Value-Based Care Is Crucial to Oncology

Value-based care initiatives are more relevant than ever, Stuart Staggs, MSIE, senior director of strategic programs at McKesson, said as he began his talk, “Value-Based Medicine: What Is It and Why Should We Care?” As the costs of health care overall and oncology increase, the goal of containing these costs is no small feat.

The bottom line is that the cost per member per month is going up both on the commercial and the Medicare sides of the equation, Staggs said. This has led in recent years to payment models such as the EOM and previously the Oncology Care Model (OCM) focusing on controlling the total cost of care, expanding what a care team means, and balancing quality outcomes and patient experience at the same time.

Cancer care, Staggs noted, has outpaced musculoskeletal conditions as a top driver of health care cost for employers in recent years.² “It’s not that paying a higher cost improves outcomes,” Staggs explained. “There’s a sweet spot in there that you have to find consistently to deliver high-quality care, access to services, and the right services at the right time to get right outcomes for patients.”

To manage care costs, employers have utilized a host of strategies, and community oncology practices may be part of the solution, Staggs said. The cost of care in the community setting is substantially lower than care in the hospital setting, making site of service an area with potential for substantial cost reduction without reducing care quality, he explained.

The “value” in value-based care is defined differently by various stakeholders, Staggs explained, but the core of the concept is providing the best possible care to patients by shifting away from volume-based fee-for-service systems and toward higher-quality, cost-conscious care. And in the end, he said, the patient’s idea of value must be front and center in oncology care.

Efficient care is a key part of the patient experience, and so is toxicity—both financial toxicity and the toxicity profiles of cancer treatments that can impact patient quality of life. A patient’s own goals of care also must be factored in, as well as how to keep costs sustainable for patients.

Staggs also highlighted the shift in risk to providers as care transforms, noting that things are done much differently than in even the recent past and that they have not gotten easier. There is more work involved and finding the resources and a consistent care team to execute value-based initiatives, which involve measuring outcomes, can be difficult. There are resources, however, and the checkpoints involved can help ensure that patients are getting proper care, he added.

Across value-based care models, there are different goals laid out for providers in terms of utilization and outcomes, which speaks to the varied definitions of value across the care continuum. These may include better pain management, advanced care planning, screening for depression, or reduced hospitalizations—a common theme across past and present models in oncology, such as the OCM.

“It’s really important that we harmonize with payers and align with the needs of the patient, because the more we can align on what’s needed, the better we can deliver for the patients and our partners,” Staggs said. With change seemingly inevitable, he stressed the importance of being part of conversations to influence these changes when possible.

“The way I talk about risk is it should be something that makes you uncomfortable on a daily basis to the point where you want to do something different, but not so uncomfortable that you can’t sleep at night,” Staggs concluded. “You want to find the right balance, and I think Arizona Oncology has found that balance doing a lot of things around quality for patients and cost at the same time.”

Finding Success in Value-Based Care

Grant Andres, DC, BSN, MSN-RN, CLSSBB, CPHQ, senior director of clinical operations at Arizona Oncology, spoke to the center’s experiences under the OCM and the EOM so far, and how its initiatives have driven cost savings and quality improvements under value-based care models. Optimization of established best practices, he said, is a major aspect of the organization’s success.

For Arizona Oncology, Andres began, it started with a quality and safety committee to provide leadership and direction, with a focus on consistent care delivery at the organization’s practices. The committee continuously works to implement quality improvement projects, with a focus on value-based care across the organization. Stemming from this initiative were others, including a committee dedicated to policies and forms, as well as an incident investigation committee, clinical standards workgroup, and a safety on site team. Together, he said, these build a foundation of quality and safety across Arizona Oncology.

Numerous quality improvement projects also propelled Arizona Oncology to success in value-based initiatives, particularly the OCM. Projects around the chain of command, patient risk stratification, use groups for technology applications, and metric scorecards are some of the ways organization members strive to improve care quality.

These and other measures have led to Arizona Oncology earning the American Society of Clinical Oncology’s Quality Oncology Practice Initiative certification and accreditation by the American Society for Therapeutic Radiology and Oncology’s Accreditation Program for Excellence.

“Value-based care does give me some hope for the future of health care,” Andres said. “…I think that has really 2 fundamentals: improve the quality of care and reduce your total cost of care.”

He highlighted best practices dictated by the EOM, which began in July 2023. Most are consistent with the OCM, including patient navigation, care management planning, continuous quality improvements, and the utilization of electronic health records. The EOM also entails new measures around the collection of electronic patient-reported outcomes and the identification of health-related social needs among patients via a screening tool.

Measurement, Andres noted, is a crucial aspect of succeeding in value-based medicine. Tools to track progress and predict trends among patients are therefore key in this endeavor. Andres also emphasized the need to work across the health care community to deliver patient-centered care.

“In our community, we have primary care, we have specialty care, hospital care, palliative care, hospice care. Our enhanced services that we offer at Arizona Oncology—including triage, navigation, social work, nutrition—connect with the community to find the right resources for our patients to have successful outcomes with their care,” he explained. Over time, implementing these strategies has led Arizona Oncology to make remarkable progress in value-based care, with reductions in the total cost of care and increased interactions with patients.

Where Primary Care and Oncology Meet in Value-Based Goals

Although oncology has been a continuous focus of cost-saving efforts, the final discussion of the evening featured a panel including Biuso, Staggs, and Andres, along with primary care physicians Melissa Levine, MD, a family medicine physician at Arizona Community Physicians (ACP) and medical director at Abacus Health, an accountable care organization (ACO) formed by ACP and Tucson Medical Center; and Michael Yim, MD, board-certified family physician and medical director at Northwest Healthcare and president of the Community Health Services Physician Leadership Council. The panel began with an audience question about how primary care doctors can strengthen their roles in the patient cancer journey and work together with specialists to close gaps in care.

“I would start by saying communication is key,” Levine said. “How many times do I have a patient who tells me they’ve seen a particular specialist, and I have nothing from that specialist? So, I would say it starts with communication.”

One way that ACP has aimed to improve collaboration has been bringing community specialists in different fields together to focus on a particular topic. One example was bringing orthopedic surgeons to develop a hip pain protocol around optimizing patients for surgery and decreasing redundant x-rays. This strategy is applicable to other disease states and has been replicated with knee pain, with others in progress, she noted.

“The irony of all these value-based systems and all these quality measures is, I think, that the more things change, the more they stay the same,” Yim said. “When you look at what they want us to do, they want us to provide the same kinds of care that our grandparents received as children—a doctor who would know everything about them, who knew their medications, their specialists, and their problems. The challenge we have is we have such a high number of patients and such a high need for physicians.”

Yim explained that these patients are also often complex, necessitating specialists for management of conditions outside of the scope of primary care. The high volume of patients creates time pressure, which represents a barrier to increased collaboration with specialists as well as personalized care. Later, Levine noted that although the past practice of making rounds to see hospitalized patients was more personal for patients and practitioners, the advent of the hospitalist movement elevated care because it allowed hospital-based practitioners to focus on hospital medicine, which changes often.

Buscema posed the question of how primary care physicians can elevate communication with hospitalists. For Yim’s part, he noted that transitional care, typically through discharge summaries, is where he communicates most with hospitals. Biuso agreed that a discharge summary sent to a patient’s primary care physician is the main point of communication—but noted that hospitalists typically do not have the time to follow up and ensure that summaries are reviewed.

Levine added that a focus on transitional care after hospitalization is crucial, as patients who have just been discharged are more likely to be hospitalized again in the next 30 days. Identifying ways to prevent exacerbations in this period is huge, she said.

Another audience member noted that, in many cases, relatively few patients constitute a substantial portion of health care costs, and raised the question of whether predictive analytics may be helpful in identifying patients who could have the highest costs. Further, he asked how high-risk patients identified by specialists could be connected with primary care models.

“I would anticipate that that’s part of the future of health care, and that is the value of the data that becomes available over time,” Andres said. “And it is just who can be adequately innovative to be able to use [those] data to the betterment of the well-being of our country, and the economics associated with health care?” Staggs agreed, adding that risk indices can look at a range of factors that can help prioritize patients who may benefit from more time with practitioners or more attention in the primary care setting.

The panel closed by emphasizing the importance of end-of-life care for oncology patients and its potential to keep them out of the hospital, improve quality of life, and save costs. “If you manage a patient’s end of life responsibly, it can have an extraordinary impact on your total cost of care,” Andres said.

In closing, Staggs reiterated that a collaborative approach to care benefits all providers in value-based models. “One thing with these total-cost models is it doesn’t matter who captures the comorbidities or takes those actions—it’s part of that episode, which is your entire care team, not just the oncology care team.” 

References

1. Dossett LA, Hudson JN, Morris AM, et al. The primary care provider (PCP)-cancer specialist relationship: a systematic review and mixed-methods meta-synthesis. CA Cancer J Clin. 2017;67(2):156-169. doi:10.3322/caac.21385
2. Business Group on Health. 2023 Large Employers’ Health Care Strategy and Plan Design Survey. August 23, 2022. November 13, 2023.
   https://www.businessgrouphealth.org/ resources/2023-large-
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