Lessons in Value From Other Specialties

Before Evidence-Based Oncology (EBO) became my primary focus at The American Journal of Managed Care, I mostly covered cardiometabolic diseases, including the major conferences—the American College of Cardiology, the American Diabetes Association, and the American Heart Association (AHA). Although I’m many years into the shift to oncology and hematology, I like checking in on my old beat, since so much of what’s happening in cancer arises from chronic disease.

And so, I spent November 16 to 18 in Chicago at the AHA Scientific Sessions, which offered interesting late-breaking trial results on the use of sacubitril/valsartan (Entresto) to prevent cardiomyopathy after chemotherapy (see Cover). However, the real gems came on the last day, during a poster session, “Behind the Curtain: How Healthcare Policy Shapes Patient Outcomes.” There, Vinay Kini, MD, MSc, of Weill Cornell Medicine, presented an analysis, “The Association of Cardiologist Vertical Integration With Care Quality, Patient Outcomes, and Utilization,”1 that should be a must-read for policy makers evaluating the future of the 340B program, Medicare reimbursement, and policies that govern relationships between hospitals and practices.

Vinay Kini, MD, MSc | Image credit: Weill Cornell Medicine

First, Kini gave an overview of the pros and cons of vertical integration: On the plus side, it should offer better care coordination with fewer duplicative tests. On the downside, he said, most studies of vertical integration show it increases costs.

Kini and his coauthors traced cardiologists’ billing patterns from 2008 to 2018, as more and more of them shifted to billing under a hospital tax ID.¹ Then, for that same time frame, they tracked some bread-and-butter quality measures for common events in their field—acute myocardial infarction and incident heart failure—to see whether quality metrics improved once cardiologists were part of a larger, integrated hospital system.

What they found was almost no difference in quality. And, as Kini pointed out, this happened against the well-documented tide of rising costs.
I asked Kini the obvious question: If the classic definition of value is quality over cost, does this mean vertical integration offers less value?

“Yes,” he replied.

It didn’t take long for others in attendance to wonder aloud whether Kini’s findings could be applied to other specialties. Such as, perhaps, oncology?
As EBO goes to press, pharmaceutical manufacturers are suing US regulators to change the terms of the 340B discount program, which many critics blame for vertical integration and harmful fallout on oncology.

Research findings vary on this point. Soroush Saghafian, PhD, of Harvard Kennedy School, has concluded that vertical integration is driving up costs and driving down quality.² Meanwhile, authors in the Journal of the National Cancer Institute who focused on metastatic prostate cancer found integration brought more use of supportive care, similar survival outcomes, and no increase in Medicare spending within the first 3 months.³ Ask leaders of independent oncology practices, however, and there’s no question they attribute the loss of smaller practices to 340B.

If the actions by pharmaceutical manufacturers in recent weeks are any sign, change is coming to 340B, one way or another.

References
1. Moghtaderi A, Magid DJ, Yuan AY, Black B, Luo QE, Kini V. The association of hospital-cardiologist integration with patient outcomes, care quality, and utilization. J Am Coll Cardiol. Published online November 13, 2024. doi:10.1016/j.jacc.2024.10.109
2. Saghafian S, Song L, Newhouse JP, Landrum MB, Hsu J. The impact of vertical integration on physician behavior and healthcare delivery: evidence from gastroenterology practices. Manage Sci. 2023;69(12):7158-7179. https://tinyurl.com/y9p32uls
3. Hu X, Lipscomb J, Jiang C, Graetz I. Vertical integration of oncologists and cancer outcomes and costs in metastatic castration-resistant prostate cancer. J Natl Cancer Inst. 2023;115(3):268-278. doi:10.1093/jnci/djac233