Looking Ahead

Barriers to the Future of Oncology Value-Based Care Are Complex but Can be Overcome

At the 2018 meeting of Patient-Centered Oncology Care^®, panelists looked to the future and offered predictions on the path of oncology value-based care.

Moderator Joseph Alvarnas, MD, of City of Hope began by listing some words and phrases that stood out to him, representing important ideas during the day’s presentations: practice transformation, data, risk, scalability, patient experience, burdens versus rewards. “If we’re going to create a future system that makes sense, we’ve got to address all these things at some level,” he said, “or we end up with a system that’s not even a partial fix to the issues we face today, much less those that will come tomorrow.”

He turned to the conference’s keynote speaker, Barbara L. McAneny, MD, president, American Medical Association, for her thoughts on the first element of practice transformation and where she foresees it heading.

Foremost on her mind, she said, was the “alarming” trend of oncology practice acquisitions by health systems, plans, or investors that are more focused on profits than on patient care. This threatens the sustainability of independent practices, which she considers the most high-quality, cost-effective site of service. On a more specific level, McAneny spoke of the need for CMS and other payers to understand that “transformation takes time and money and a significant amount of effort” and that more patience might be warranted when evaluating restructuring efforts.

Alvarnas picked up on something McAneny mentioned—“there is a cost to getting this right that involves investment”—and asked panelist Michael Kolodziej, MD, FACP, vice president and chief innovation officer, ADVI Health LLC, how to bring physicians into the transformation without imposing unbearably high costs of time and burden on them.

Kolodziej offered that it’s important to “recognize that technology has to be an enabling tool, as opposed to an impediment.” He said that this became especially clear to him as he heard the grievances of his wife, who is an oncologist, when her practice migrated to a new electronic health record (EHR) system. He also spoke of a need to standardize processes—beyond EHR systems— to improve care and “use technology and data to understand the optimal way to treat each individual patient.”

He added that he thinks these efforts will largely be funded by the private sector, not by physicians, and that reaching the goals of value-based oncology will require some big changes, both in terms of payment models and the amount of attention it gets in Washington, DC. Most of the focus is on drug prices, Kolodziej said, not more specific issues, such as the unintended consequences of a Competitive Acquisition Program, which could be an alterna- tive to the buy-and-bill system of acquiring Medicare Part B drugs in cancer care.

For a different perspective on the investments needed to provoke transformation, the conversation turned to Brian Loy, MD, physician lead, oncology, laboratory, and personalized medicine, Humana. He explained that as a payer placing bets on solutions to a problem, he sees opportunities for a variety of stakeholders, including employer groups, to assign themselves roles and determine how to pay for new models of care. Otherwise, he said, it’s like “delivering furniture to someone’s new house when they’re still pouring the foundation.”

As the only nonphysician on the panel, Christian Downs, JD, MJHA, executive director, Association of Community Cancer Centers, offered his view on the barriers to success under the Oncology Care Model (OCM). Considering the tremendous amount of work invested by the Center for Medicare & Medicaid Innovation to launch and maintain the model, as well as the time put in by physicians responding to OCM requirements, he is not convinced that improvements in experience have been worth this amount of effort, he said. In addition, he sees the need for reforms that cut across disciplines and look at the total cost of cancer care instead of breaking costs down by specialty.

Another barrier, according to McAneny, is the head-spinning rate of change in value-based care models like the OCM. “People invest in this, and they create relationships with payers and with other physicians, and they restructure their practice, and then before we even have time to see whether it’s going to work, we are already rearranging it to the next flavor of what the value-based care will be,” she said. “We need to have the ability to have some time to actually see if something works before we change the rules of the game the next time around.”

It’s also a challenge for physician practices to balance the demands of Medicare and commercial payers. “Everyone has different quality measures, different pathways, different values. We have to get some consistency, because otherwise physicians feel like they have 50 people shouting their priorities at them every day,” McAneny said.

In discussing how to fix these problems, Kolodziej called CMS “the natural convener” because it has the bulk of patients and drives much of the healthcare conversation, but he worried that the lessons learned and potential achievements would be drowned out by political considerations. Loy added that many of the steps toward improvement in oncology consume time and resources and require finesse, such as shared decision making, patient value discussions, and advanced care planning.

Circling back to the discussion about burdens on physicians, Downs voiced concerns about rates of burnout and stress on physicians in cancer care workforce. With every new payment model announced, he said, he fears that more older oncologists will lean toward retirement and more medical school students will choose other specialties.

Alvarnas proposed a hypothetical for Kolodziej: If he could magically transform himself into CMS Administrator Seema Verma or HHS Secretary Alex Azar, what would he do? Though Kolodziej quipped that he’s not interested in that hypothetical, he offered a suggestion of increasing transparency and dialogue between healthcare delivery professionals on the front lines and the decision makers within the federal agencies and commercial payers. He also said that CMS should sit down with the tech industry more than it already has in its efforts to regulate telemedicine and health information technology.

“We’re not going to get anywhere unless we can really adopt a collaborative approach to this,” Kolodziej warned, and he reminded all stakeholders to keep in mind the goal of giving the best care possible no matter where a patient lives. “Irrespective of how sophisticated the doctor is in that area or what kind of support the hospital system is given, irrespective of all that stuff, we want to make sure that we don’t have a 2-tier delivery system.”

Finally, Alvarnas asked the panelists to channel their inner psychic and predict if these issues will have been solved 10 years from now. Downs thought that things will have improved, although not achieved perfection, helped in part by the technology that is being developed now “from a data standpoint, particularly around social determinants of health and risk stratification,” he said.

Loy concurred that social determinants of health are an important frontier that will be more fully explored, and he posited that the healthcare system must find sustainable ways to finance new technologies.

Kolodziej’s answer was succinct and not entirely optimistic: “We will deliver much better, much more personalized care to our patients irrespective of where they live, but we will still not know how to pay for that care.”

In McAneny’s view of the future, as we cope with the current funding crisis, we will see “the pendulum swinging back from aggregation into some disaggregation, so that we recognize that healthcare is local and that we build new structures” for sharing data and best practices.

“I’m an oncologist, so I’m an optimist,” she concluded. “I think that we will pull it together and come up with a system where we’re delivering healthcare to everybody at an affordable manner, because we have to, and we will have tried everything else first.”

Alvarnas concluded the session by thanking the panelists and tying their discussion back to the name of the conference.

What Oncology Care Management Means to Providers, Patients

“What was so inspirational is that the conference is called the Patient-Centered Oncology Care^® event, and when we talk about social determinants of health and delivering care closer to home in a way that engenders forming relationships with patients that are delivered in the pursuit of wellness and well-being and healing, as opposed to maintaining a chronicity of disease, that really seems to be the crux of where we’re trying to go through these conversations.”Care management is relatively new in cancer treatment, but it quickly became the heart of value-based care and a core requirement of CMS’ Oncology Care Model (OCM). As a panelist at Patient-Centered Oncology Care^® (PCOC) described it, care management calls on practices to deal with “everything in between” the physician appointments, including nutrition counseling, dealing with depression, and getting connected with a survivorship program.

Rose Gerber, cancer survivor and director, patient advocacy, Community Oncology Alliance, chaired the panel, which featured providers and a patient with stomach cancer now on his seventh treatment.

Gerber asked a series of what she called “bundled questions” to Beth Wittmer, RN, OCN, senior manager, care management program, Florida Cancer Specialists (FCS), starting with the most basic: What is care management? She followed with: What does being in care management mean to the patient? How are patients contacted? In the era of the OCM, what are the requirements? And has the OCM created savings?

FCS had an advantage when the OCM began, Wittmer said, because it had already launched its care management program. FCS separated care management from the nurses who took care of patients in the clinic and created a dedicated staff for this purpose, including nonclinical staff who handle some of the intake tasks.

“You know [patients treated in the clinic] are going to be sick in 3 days, but you don’t have time to make those calls,” she said, because a new round of patients has arrived for treatment.

Care management now has its own team and its own protocol. “Our biggest goal is that we are proactive in our care,” Wittmer said.

Gerber asked if patients appreciate the phone calls, and Wittmer acknowledged that not all do. Patients get calls when they start treatment and at intervals based on where they are in their care. Patients who are starting a third or fourth course of treatment may say, “I’ve got this,” but that reaction is preferable to having too many patients show up in the emergency department, Wittmer said. Care management is also integrated with FCS’ pharmacy to improve adherence to oral oncolytics.

FCS has adjusted its protocols along the way. Wittmer said the required language in the OCM letter to patients can be confusing and disruptive, and it made some think the initial care management phone call was Medicare fraud. FCS now sends out a welcome packet. “As with anything new, you go through some bumps and bruises,” Wittmer said.

When patients are set up in care management, they are told that it is available 24/7, which is a requirement of the OCM. Ultimately, this works for seniors, Wittmer said. To physicians in the room, she said, “Patients don’t like calling you ... but they have no problem calling a nurse.”

Lani Alison, MS-HCQ, RN, vice president, clinical affairs at Regional Cancer Care Associates (RCCA), faced a tall order when she took on implementing the OCM across more than 30 locations in 3 states. “We changed the culture of the organization,” Alison said.

It was Alison’s task to help the oncologists understand the metrics and get at the heart of the question: “What makes the patient go to the emergency room?” Even though it might differ among locations, the answer mattered, because it helped RCCA fix issues and meet the terms of its value-based contracts. Better coordination with primary care physicians became essential. “We live and die from referrals from primary care physicians,” Alison said, and RCCA had to know more about these patients and existing comorbidities. “You are in for the total cost of care if your patients die of a heart attack or [one] gets hit by a bus—we’re still responsible. We have to make care coordination part of our DNA.”

Most of the RCCA locations are in New Jersey, which historically has ranked near the top among states for Medicare spending at the end of life.¹ RCCA has put a significant focus on survivorship and palliative care planning so that patients have discussions early on about how their values and religious beliefs should guide their care. Survivorship “has become a hallmark of our daily practice,” Alison said.

RCCA has tried to dig deep into understanding how a small group of patients accounts for a disproportionate share of the costs, Alison said: “We’ve created our own risk stratification,” paying special attention to how social determinants of health affect care and outcomes.

The good news, she said, is that once oncologists understand the metrics and where they rank among their peers, they want to improve. “Oncologists are [like] really frustrated NFL players. They are competitive,” she said.

Like other practices, RCCA finds the greatest challenge is the rising cost of cancer therapies. The oncologists do point this out, Alison said, noting that there are some outliers “who are still wired to treat, treat, treat.”

But slowly, as the nurse navigators and other team members are working at the top of their licenses, care management is making a difference in the bottom line.

Gerber next introduced Wes Hall, a 75-year-old patient at FCS who has taken part in clinical trials on and off since receiving a diagnosis of stage IV stomach cancer in 2013. Hall is an example of patient who has formed a close relationship with a primary oncologist “that he has a lot of faith in,” she said.

Hall shared how far cancer care has come since he was growing up, when a diagnosis meant “exploratory surgery,” he said: “They closed you up and sent you home, and that was it.”

He went through his litany of treatments, from radiation to targeted therapy to immunotherapy, which have kept him alive but caused adverse effects, including severe neuropathy and gastrointestinal effects. But he values his bonds with his oncologist and the staff. He said he can get hydration whenever he needs it, and when his cancer progresses on a clinical trial, he is referred back to his primary team at FCS and can get in within a day.

Last year was rough for Hall. He spoke with Evidence-Based Oncology^TM in early February 2018 after learning that treatment on a clinical trial had failed.² For most of his cancer journey, scans showed lesions only on his stomach or liver, but in May they appeared on his scapula, lymph nodes, femur, and colon. Radiation and another round of treatment reduced his tumor markers significantly, and scans showed some shrinkage, but Hall lost 33 pounds in 12 weeks.

To participate in the panel, Hall had to work with his oncol- ogist to regain some strength. “Just 2 things bother me. The residual neuropathy [and what it suggests]—I haven’t been drinking, but it just looks like it.”

He also gets frustrated that when he takes part in a clinical trial, the protocol requires that he leave the trial with the smallest progression, even if he is feeling better.

Hall shared what he called a few pieces of trivia: Through October 2018, his insurance company had been billed $1.274 million for his care, and his co-payments are 34% of his total income.

“I have a very good relationship with the people that I work with,” Hall said. “You’ve got to keep a good attitude that you’re going to make it.”

REFERENCES:

1. Maron M. Op-ed: improving end-of-life care should be a priority for New Jersey. NJ Spotlight website. njspotlight.com/stories/18/12/11/op-ed-improving-end-of-life- care-should-be-a-priority-for-new-jersey/. Published December 12, 2018. Accessed January 18, 2018.
2. Caffrey M. The clinical trial and the patient’s voice: “I’m extremely lucky to be alive.” Am J Manag Care. 2018;24(SP2):SP53-SP54.

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