Keeping Ahead of the Curve in the Transition to Oncology Value-Based Payment

At a session of The American Journal of Managed Care^®'s Patient-Centered Oncology Care^® 2018 meeting, held November 16 in Philadelphia, panelists shared their views on the future of oncology value-based payment models and how they as payers and providers can help advance these models.

Moderator Joseph Alvarnas, MD, started the discussion by acknowledging how keynote speaker Barbara McAneny, MD, laid out a framework of challenges in balancing value and sustainability with better outcomes and patient experience. He asked the panel about the definition of value-based care, which he called “part platitude, part wastebasket.”

While value-based care is “a hodgepodge of models,” explained Samuel Young, MD, senior medical director, Medicare Florida Blue, its core intent is to improve patient health outcomes and quality of life for patients at lower cost. Marcus Neubauer, MD, chief medical officer, US Oncology Network, agreed with that assessment and added that it arose because the current fee-for-service system is unsustainably expensive. Neubauer sees CMS as the major catalyst for the conversion to the alternative of value-based care, and US Oncology believes in being part of that transition.

Circling back to the meeting’s theme, Michael Ruiz de Somocurcio, vice president of payer and provider collaboration, Regional Cancer Care Associates, said that value must have the patient front and center, because improving quality of care is not simply checking a box. Fortunately, by taking patient-centered steps like keeping patients out of the hospital, those efforts have a ripple effect that improves care quality and lowers costs.

Complicating the matter is that the goal of improved outcome is defined differently for each patient, added James Helstrom, MD, chief medical officer, Fox Chase Cancer Center. Cancer type and stage will determine whether a patient is concerned with quality of life or is just trying to attain survival. Young agreed that there needs to be a condition-specific approach to measuring cost and quality.

Another issue, according to Young, is that incentives are misaligned from the patient, payer, and provider perspectives. Commercial plans have members who frequently change jobs and plans, meaning they may not reap long-term financial benefits after paying the upfront cost of a treatment, but they still want providers to act in the best interest of their patients.

Doing the right thing for patients is what actually led physicians in the US Oncology Network to become interested in value-based care before it became “trendy,” said Neubauer. They recognize they have a responsibility to manage cost of care and are taking steps to do so, leading him to conclude that any efforts to change culture must be physician-led.

Helstrom agreed on the importance of provider-led change, saying that edicts from administrators automatically engender resistance. He suggested that by keeping costs out of the discussion and simply encouraging them to do the right thing clinically, cost reductions will typically follow. Ruiz de Somocurcio added that value-based changes also must fit within physicians’ workflow and should optimally be supported by hiring nurses, social workers, or patient navigators to alleviate physician burden.

Another “tremendous hurdle” to broader adoption of value-based care is full data exchange and transparency, said Young, which is hindered by the limitations of electronic health records. Having fully transparent 2-way data exchange will not only allow physicians to compare their cost and quality metrics with their colleagues’, allowing their competitive natures to drive improvement, but also would enable consumers to choose their providers on objective performance measures instead of word of mouth.

A discussion about value in cancer care could not omit drug prices, as Alvarnas mentioned the expensive new treatments that are resulting in better outcomes but also skyrocketing costs. Neubauer explained the role of providers in controlling drug costs; although they cannot promise payers that they will not use checkpoint inhibitors, they can commit to using them responsibly and identifying patients who are not likely to benefit.

Ruiz de Somocurcio offered a different perspective, saying that a focus on other low-hanging fruits is more likely to yield savings than uncontrollable drug costs. His organization is looking into the use of new biosimilars but is also identifying cost-cutting areas like reducing emergency department visits, performing office-based imaging instead of in hospitals, and using pathways to reduce variation in care.

Bringing the conversation back to the theme of the meeting, Alvarnas asked how the panelists work toward including patient goals in the value equation. Neubauer explained that his system has implemented treatment plans to formally outline a road map before starting treatment so patients and care providers can refer back to it.

“In our transition to value-based care, I’ve seen patient experience improve,” he attested.

From the payer perspective, Young explained that as custodians of members’ health data, his organization has launched data platforms that give patients a “virtual care community” that ties not only the patient’s life plan but also opinions from their family members, social workers, and other stakeholders, allowing the care provider to access all of that input and bring it into the care discussion.

“Ultimately, this falls on us to bring together all these information sources so that everyone can see what’s best for the patient,” he said.

As Alvarnas asked the panelists to provide their final thoughts, each of them agreed that the shift to value is not going away. Ruiz de Somocurcio emphasized that value is here to stay, giving the example of the mandatory radiation oncology bundles announced by HHS Secretary Alex Azar last week. In terms of the larger shift toward value, he said, “you don’t want to be last in line when that happens, so it’s time to do it now.”