Lessons From the Pandemic to Scale Cancer Care Innovation

Eight days before the deadline for applications to join the next iteration of the CMS’ value-based payment model for oncology, physician-researchers and other stakeholders gathered in midtown Manhattan to discuss affordability, technology, and innovation in cancer care.

In June 2022, CMS announced that the successor to the Oncology Care Model (OCM) would be the Enhancing Oncology Model (EOM), to launch July 1, 2023. The OCM allowed practices to learn the model before taking on 2-sided risk on a voluntary basis, but the EOM will require participants to take on risk immediately, even for practices new to the concept. In addition, patient navigation payments will be cut in the new model. Following the drive at CMS to infuse health equity across all services, the EOM has significant new reporting requirements, including tracking demographic information and how well practices deliver care for patients based on their social determinants of health (SDOH).¹

“The time is right for this conversation,” said Emeline Aviki, MD, MBA, of Memorial Sloan Kettering Cancer Center (MSKCC), which partnered with The American Journal of Managed Care®’s (AJMC ®’s) Institute for Value-Based Medicine® to present the event. Aviki, a gynecologic surgeon, founded and heads MSKCC’s Affordability Working Group,² and she led the development of order sets embedded in MSKCC’s electronic medical record (EMR) to screen patients for financial toxicity, in the same way that patients are screened for other risks that affect health, like genetics or smoking.

The pandemic fueled innovation across health care, and the challenge now is how to scale it, she said.

In an interview with AJMC® before the meeting, Aviki noted that the telehealth boom of the pandemic has scale-up lessons for all aspects of oncology care so that other critical aspects are included.

“In addition to offering patients convenient oncology visits, it also offers the ability to scale non-oncologic visits that are very helpful for patients, for example, psychiatric care and supportive care for pain management,” she said. “It would allow you to get those services that are really in short supply to patients, no matter where they are.”

Looking Back at the OCM
While the evening’s discussions mostly looked to what is ahead for cancer care, Stephen Schleicher, MD, MBA, chief medical officer at Tennessee Oncology, reviewed what he has learned by asking, Did the OCM truly fail?
“According to Twitter, the answer is yes,” he said, referring to social media chatter. Overall, the model cost Medicare more than $315 million over 2.5 years.³

However, the answer changes when you ask those practices that actually participated, Schleicher noted. “The model overall might have failed, but groups that actually took it seriously did phenomenally well,” Schleicher said.

Besides Tennessee Oncology—a founding practice of OneOncology—others that did well included Florida Cancer Specialists, The US Oncology Network, and Brigham and Women’s Hospital, he said.

In Tennessee Oncology’s experience, Schleicher said there are 4 levers to success in value-based oncology care: drug utilization, care management, clinical trial access, and end-of-life care. In turn, these are built on a foundational triad of culture, people, and data analytics.

Of the 3 factors in the foundation, culture is the hardest to shift, he said, and at Tennessee Oncology, it came down to internal networking and communications to get 1200 employees to buy into the OCM and believe in it. No one was excluded, he said.

Videos sent to employees addressed questions about the OCM such as, “What is it? Why does it matter?” and managements was transparent about benchmarks and costs to get everyone in alignment. Staff were kept apprised of news like patients’ rates of emergency department (ED) visits and hospitalizations dropping over the past year.

To achieve the goal of keeping people out of the hospital, 2 years ago Tennessee Oncology created a dedicated, centralized care transformation team to rapidly triage patients and resolve their symptoms more quickly.
They also created an internal palliative care team and embedded physicians and advanced nurse practitioners in the clinics 2 days a week to be more patient-centric. Being physically located together is important, Schleicher said, because patients don’t want extra visits and it makes the transition later, if it happens, easier.

Data Analytics: Knowing What to Do and Asking the Right Questions
Another factor in Tennessee Oncology’s success with the model is the tracking of metrics and distributing them to providers on a regular basis—not to punish them, but to show them how they are performing against their peers in oncology, Schleicher said.

“You don’t know how you’re doing until you know how you are doing,” he said.

Among the metrics tracked in real time—even prospectively—are:

• ED and hospital rates by patient, provider,
  and clinic
• Staging completion within 30 days of first visit
• Palliative care referrals
• Active treatment at the end of life
• Adherence to pathways

Financial details about drugs, especially high-cost, low-value medications
As one such example, Schleicher cited the use of denosumab (Xgeva) to prevent bone fractures, which costs Medicare $6744, vs zoledronic acid (Zometa), which is available as a generic and costs $42. If the patient does not have any renal concerns, then the less expensive medication is just as effective as the pricier one. The impact of converting 50% of patients taking Xgeva to Zometa reduced spending in the OCM by as much as $3 million, which was achieved by internal education and by telling doctors ahead of time what the financial impact of their decisions would be.

“You need information to influence change,” Schleicher said. In addition, the internal culture allowed him to share that information without fear of reprisal.

Another way to impact drug costs is through clinical trials, in which a participating patient receives the medicine for free. Through precision medicine matching, physicians can place an order for “molecular help” in the EMR and receive a result of all available clinical trials within 24 hours.
Event cochair Robert Daly, MD, MBA, a medical oncologist who specializes in lung cancer at MSKCC, asked Schleicher to name the biggest factor behind the decrease in ED utilization.

“It’s hard to know,” Schleicher responded. But he added that at Tennessee Oncology, “the default is how do I keep them out of the ER vs the easy answer, which is to go to the ER.”

Health Care: Operating in a Different Context
Before describing the innovations launched at MSKCC, Wendy Perchick, its senior vice president of strategy and innovation, sketched a picture of what is at risk in health care today if nothing changes: access, outcomes, and sustainability.

“To say health care is under stress is to put it mildly,” Perchick said, and the threat that one day there will be failures in what health care should be delivering is “very real.” She cited several factors that are a backdrop for this chaos, from individuals who are disoriented and “seeking expertise wherever they can find it” to a shift from an old industry filled with stalwarts to “an ecosystem that is not respectful of our traditional roles, and I would say they shouldn’t be.”

Through partnerships and technology, MSKCC is extending its reach beyond its Upper East Side neighborhood in Manhattan. Through its MSK Direct program, for example, oncology services are offered to 137 partners with 6 million covered lives, mostly via employers and unions. The idea is to “be present even before people need us,” Perchick said.

Its InSight Care, which Daly developed and leads, seeks to create earlier interventions to reduce inpatient use and cost. Satisfaction among patients with cancer has soared, while their urgent care center visits are down 20% and their inpatient admissions are down 18%.

The interventions include the development and use of predictive models, an app for patient-reported outcomes, the development of algorithms and care pathways, a new care team, and integrating InSight Care into the delivery model. “It can’t be clunky,” she noted.

InSight is now evolving into connected care in the home, Perchick said, including remote patient monitoring.

Her office is also using applied data science to understand financial toxicity, which affects a quarter of patients after they start treatment. Of that 25%, only 22% had applied for financial assistance and only 27% had applied for social work funds. As of this year, all patients are automatically screened for financial toxicity when they are treated by the center.

Lastly, MSKCC is looking at “the space before cancer” to identify and manage those with a higher risk for disease, which is more easily and less expensively treated when caught early. To that end, MSKCC rolled out a Digital Guided Risk Management Program, which uses virtual methods to provide information to people at higher risk of cancer, in conjunction with their regular health care delivered locally.

Partnerships in Care in the Outer Boroughs and Long Island
While MSKCC extends its reach virtually, another partnership in New York City has colocated primary care physicians and cancer specialists together to serve a population composed mostly of Black, Indigenous, and people of color (BIPOC), said Navarra Rodriguez, MD, president and chief medical officer of AdvantageCare Physicians, a large primary and specialty care practice with half a million patients across New York City’s 5 boroughs as well as Long Island.

Last year, it formed a partnership with New York Cancer & Blood Specialists to colocate hematologists-oncologists on site to provide for a seamless therapy experience. This way, “they don’t have to leave Brooklyn or East New York to get their chemotherapy,” said Rodriguez.

In addition to being mostly BIPOC, half of AdvantageCare’s patients have government paid-health insurance, and “care must be culturally and linguistically aligned,” she said.

Rodriguez touched on how her job as a primary care physician intersects with different aspects of cancer care. “Wellness and screening—that’s easy, that’s our day-to-day,” she said.

It’s later in the process that things can get tricky and break down, she said, such as in the treatment phase. “That’s when the primary care provider can get lost in the background,” Rodriguez said.

The Future Is Diagnostic Testing, Artificial Intelligence, Kwo Says
Until earlier this year, Liz Kwo, MD, MBA, MPH, was the deputy chief clinical officer at Anthem Blue Cross Blue Shield. Now she is the chief medical officer at Everly Health, a fast-growing, data-driven startup that sells direct-to-consumer (DTC) at-home lab testing kits and is also partnering with payers and employers to deliver home-based diagnostic testing, such as colon cancer screening. Last year, Everly also acquired Natalist, a DTC provider of home test kits focused mostly on female reproductive health and wellness.

The surge in home testing is being fueled not only by the pandemic, which delayed care and illuminated SDOH factors impacting patients across the country, but also because of how people are “seeing and purchasing care,” Kwo said.

“How do you consume health care in a way that makes you feel vibrant and not stigmatized?” she asked.

Kwo, an entrepreneur, touted the future of artificial intelligence (AI) in health care, saying it will be able to positively impact costs, the patient experience, and population health, and improve the work life of providers as well.

For instance, AI-enabled prior authorization processes could automate 50% to 75% of manual tasks, freeing everyone to focus on complex cases and actual care delivery and coordination. Or AI could augment lung cancer screenings, resulting in increased accuracy, earlier detection, and improved outcomes.

Or, during pregnancy or disease treatment, communicating symptoms through an app, a chatbot, or straight to a physician’s dashboard could flag potentially serious complications earlier.

“If you can track symptoms early to prevent [or] to predict [difficulties], you could prevent things such as dehydration in chemo” or flag potential problems in a pregnancy, she said.

“I think it’s the future of where we can go,” Kwo said. 

References
1. Fact sheet: Enhancing Oncology Model. News release. CMS; June 27, 2022. Accessed June 27, 2022. https://www.cms.gov/newsroom/fact-sheets/enhancing-oncology-model
2. MSK team aims to make cancer care more affordable for patients. News release. Memorial Sloan Kettering Cancer Center; May 12, 2022. Accessed September 26, 2022. https://www.mskcc.org/news/msk-team-aims-make-cancer-care-more-affordable-patients
3. Keating NL, Jhatakia S, Brooks GA, et al. Association of participation in the Oncology Care Model with Medicare payments, utilization, care delivery, and quality outcomes. JAMA. 2021;326(18):1829-1839. doi:10.1001/jama.2021.17642