Oncology Stakeholders Must Align in the Pursuit of Health Equity, Value-Based Care

Innovation in oncology has created a transformative era in cancer care from point of diagnosis to treatment modalities to patient outcomes. Despite this progress, cost and structural barriers within the cancer care delivery system continue to limit improvements in outcomes due to health disparities in historically underserved communities, said David Eagle, MD, chair of legislative affairs and patient advocacy, New York Cancer & Blood Specialists (NYCBS), Patchogue, New York.

Eagle

Eagle and Jeff Vacirca, MD, FACP, chief executive officer and chairman, NYCBS, served as cochairs of a session of the Institute for Value-Based Medicine®, held in New York, New York, on February 8, 2023. The American Journal of Managed Care® presented the event in partnership with NYCBS.
Speakers covered initiatives for advancing value-based cancer care in the community setting, including a cooperative model between NYCBS and Memorial Sloan Kettering Cancer Center (MSKCC) that aims to better align their oncology providers. Others addressed health equity and the shift from the Oncology Care Model (OCM) to the Enhancing Oncology Model (EOM), a 5-year pilot set to begin July 1, 2023.¹

Describing “the good, the bad, and the ugly” of oncology, Eagle acknowledged advancements made in precision medicine while highlighting how structural barriers and affordability concerns are growing, not shrinking. “We’ve got a payer community with cost-sharing models that are really designed for primary care, and we have specific oncology drugs with high-cost branded products without appropriate generic substitutes,” explained Eagle.

Amounting to $103.5 billion in revenue for 2019, oncology drugs currently dominate the medical benefit spend.² More than one-third of specialty drugs in the pipeline are in oncology; rising costs of these novel agents present a significant financial burden for community practices and patients.
“We’ve got people that have just simply been left out of the system, and a legacy insurance model that’s built around employment. If you look at certain areas, the average life expectancy for a person can vary by 25 years just between neighborhoods in the same city. If you want to predict how long people are going to live, about 20% of it is the medical care that they get, and about 80% is where they live and how they live,” said Eagle.

“We have this focus on health equity, but we’re really just starting—we’ve all been in the same storm but not in the same boat. So, how can we all get in the same boat? How can we get aligned?”

MSKCC and NYCBS Cooperative Model

Vacirca

Vacirca and Elizabeth Jewell, MD, MHSc, FACOG, FACS, director of surgery at the Monmouth and Basking Ridge locations for MSKCC, discussed the cooperative model between their respective health systems that aims to streamline communication and prioritize value-based care among providers.
COVID-19 was the catalyst for the partnership, Vacirca said. The complexity of health care delivery—exacerbated by increased hospitalizations, fear of infection, and more restrictive hospital policies—drove the need for better systems of care.

“It started when MSK reached out to us to have a discussion on how we can manage this awful consequence of COVID[-19] together,” Vacirca said.

“Their patients were getting admitted to these hospitals across Long Island and New York City and there’s zero communication—no one would pick up the phone and call the attending oncologist or surgeon and say, ‘Hey, your patient’s here in the hospital, what do you want us to do? What tests do you need done while the patient’s here? How do you want us to arrange a follow-up?’

“A 5-minute phone call will completely change your patient interaction and the logistics of that patient admission—we get that patient out sooner, healthier, and with better follow-up,” he said. “But it never happens.”

Seeking to change the patient experience by ensuring continuity of care and building personal relationships with MSKCC physicians, the partnership, called Shared Care, uses the following workflow:

Establishing a primary clinical contact: This is Gurmohan Syali, MD, co–chief medical officer, NYCBS.

Handling volume: An MSKCC patient is admitted to the hospital.
Communication: NYCBS is notified; Healthix is used to begin coordination of care between teams.

Patient experience: The NYCBS physician sees the patient and arranges prompt follow-up.

Doctor feedback: MSKCC and the NYCBS physician collaborate on tracking admission, discharge, and care provided.

Discharge: The patient returns to the MSKCC physician to continue care.
“[NYCBS] are outpatient doctors, seeing patients in the clinic, managing standard of care, chemotherapy, radiation for hematologic patients, but we don’t do things like bone marrow transplant, we don’t treat acute leukemia, we don’t do complicated surgery. So, what a wonderful opportunity to work together,” said Vacirca.

“This is not a normal relationship between a cancer hospital and a community-based practice, and it was so outside the norms of the MSK doctors,” he said. “If I was having my patients followed by another practice, I’m going to have a tremendous amount of misgivings. It took us a little while to earn the trust of each other.”

Partnerships in clinical care were relatively new for MSKCC, noted Jewell, an obstetrician-gynecologist who additionally serves as interim associate deputy physician-in-chief of strategic partnerships.

Prior to the pandemic, MSKCC focused primarily on reducing inpatient constraints by partnering with hospitals outside New York to help patients in their regional care network gain access to care closer to home. This has since changed, said Jewell, with MSKCC now expanding to focus on differentiated cancer care and become a preferred quaternary, or highly specialized, cancer center regionally and nationally.

Their Shared Care program has been key to this pursuit, she said. A team of nurses and medical directors communicates daily with the MSKCC provider and the outside provider, as well as caregivers and patients, to provide reliable, continuous updates and feedback on patient care.

“The role of the Shared Care program has been to develop improved communication with speed, accuracy, and efficiency with the outside doctors. Many times during the day patients would previously reach out to offices, but I’m in the operating room and I am not going to get that message for 12 to 16 hours. Now, the nurses and medical directors call in to the operating room and they get immediate feedback to manage disasters, triage problems, and to keep the care going,” explained Jewell. “The guiding principles here have been all around development of trust, making it user-friendly, and then measuring our performance around this.”

Since the launch of the model, volume at NYCBS has grown to more than 50 to 60 patients being seen per day, noted Vacirca, with more hospitals now involved to expand the program’s footprint. Along with high patient and provider satisfaction, the model has reduced readmission rates by half, he said, from 14% to 7%, while achieving an 8% decrease in average length of stay.

Given the success of the Shared Care program, other synergies and new partnership options have been explored by MSKCC, including in the outpatient sector. Cross-referrals for out-of-network patients, benign hematology, primary care, and obstetrics and gynecology are being provided by MSKCC to community-level practices such as NYCBS, which have in turn begun referring patients to MSKCC for second opinions, research, and complex care (eg, surgery, clinical trials).

NYCBS and MSKCC have additionally collaborated on the recent launch of their cancer care practice in the Flatbush neighborhood of Brooklyn, New York. “The highest population density in the United States is in Brooklyn, which has more diversity than almost any other US city, and Flatbush is in the epicenter,” explained Vacirca. “There’s nothing within 2 miles; there’s no doctors in the cancer care arena, let alone a [cancer center] sitting in the middle of Brooklyn.”

“We function in Brooklyn as what we call a captive PC [professional corporation], which is basically a private practice model for MSK physicians,” added Jewell. “We wanted to be able to provide local care where there was diversification. There is a very large African American, Asian, Hispanic community that was lacking access to MSK. I think this is the beginning of the future for us.”

Health Equity Initiatives in the Community Setting
In aiming to ameliorate cancer health disparities, Sashi Naidu, MD, director of research for Carolina Blood and Cancer Care Associates in Rock Hill, South Carolina, and Susan Sabo-Wagner, MSN, RN, OCN, executive director of clinical strategy for Oncology Consultants of Houston, Texas, spoke on their organizations’ respective initiatives to address social determinants of health (SDOH) and other barriers to equitable cancer care.

SDOH have major implications from a clinical and cost perspective, noted Naidu. He referenced findings from an American Association for Cancer Research report that showed 34% of all cancer deaths could be prevented if socioeconomic disparities were eliminated.³ Moreover, eliminating health care disparities for members of racial and ethnic minority populations would have saved $230 billion in direct health care costs and more than $1 trillion in premature deaths and illnesses between 2003 and 2006.³

Most worrisome is the lack of progress on health equity in oncology. Although precision medicine has made substantial advances in patient care and outcomes, Naidu highlighted that the genomic data used to inform the development of oncology drugs continues to exclude minority groups of Asian (2%), African (2%), and Hispanic (1%) ethnicity while favoring those of European ancestry (nearly 80%), according to the GWAS (Genome-Wide Association Studies) global database (as of 2018).⁴

“What we know is that failure to address the biases that we all have in health care provision and genetic databases will make existing disparities worse,” said Naidu.

Black men and women are associated with 19% and 12% higher cancer mortality rates, respectively, than comparable White patients.⁵ As rural communities become more racially and ethnically diverse,⁶ minority groups that already face high risk of inferior cancer outcomes may be at even greater risk.

“We represent the rural patient population. There is not easy access like there is in New York to a tertiary care center, and it only gets worse as you go even further south from us. So, we need to try to bring those processes into our small facility,” Naidu explained.

“Lack of screening, access to trials, and access to care due to financial toxicity; payer-related factors; SDOH impact on outcomes; and lack of next-generation sequencing [NGS] and other types of precision medicine testing—all of these factors are what we have seen leads to cancer health disparities.”

The No One Left Alone (NOLA) initiative from Carolina Blood and Cancer Care Associates seeks to address several of these disparities through value-based care models, Naidu said, focusing on SDOH, health care access, and clinical trial participation as follows:

Improve SDOH data collection: Mandate collection and reporting of key data elements to better understand the subpopulations and their health outcomes.

Improve access to cancer care: Increase screenings by extending clinic availability, including late-day hours and weekends, and reducing financial toxicity.

Improve access to testing and therapies: Include appropriate biomarker testing and leverage findings to select appropriate treatment options, while reducing costs by using generics and biosimilars.

Increase clinical trial participation: Identify community clinics serving these patient populations, provide customized materials to increase participation, and leverage real-world evidence to better understand the impact of disparities on patient outcomes.

Naidu said patients entering the clinic are provided with an extensive questionnaire that helps the practice identify SDOH for each individual. The data are tabulated by clinical staff who provide actionable steps on potential secondary screenings, germline testing, and clinical trial eligibility, which are supported by community-level partnerships.

Pilot studies within the NOLA initiative have shown improvements in NGS testing by solid tumor type and increased identification of actionable mutations through these tests, he noted.

“Before we started NOLA, these patients would not have had this testing done. In the community setting, in the rural setting, we see that the amount of testing that patients have is woefully inadequate,” Naidu said. “As community oncologists, we know all of cancer therapy is going towards genomics and biomarkers—that’s how we’re determining new therapies.

And if we don’t do the testing, if we don’t know what we don’t know, our patients will not get the right type of treatment.”

The Holistic Oncology Patient Equity (HOPE) initiative from Oncology Consultants is similarly taking this actionable approach to SDOH for the patient populations it serves in Houston, Texas—the fourth-largest, and most diverse, city in the United States.⁷

Referencing one’s zip code as the best indicator of health outcomes, Sabo-Wagner noted that Oncology Consultants has 12 medical oncology and 2 radiation oncology facilities that sit 8 to 10 miles apart across the entire city, allowing the practice to provide access to quality care closer to home.

“We take 60% of the payer population in Houston—that’s commercial, Medicare, Medicaid, and Medicare Advantage. We’re there for the patients in their communities and taking care of the population of patients 65 and older that really need the care,” she said.

“We wanted to impact our patients in a way that was scalable, so that if other community practices across the nation want to impact their patients as well, they could. Every community practice across the nation is seeing all different sorts of diversity.”

The HOPE team, consisting of 2 nurse navigators and 5 culturally competent community health workers (3 Spanish speaking, 1 Vietnamese speaking), leverages technology to identify the “next best actions” to close patient SDOH gaps, explained Sabo-Wagner. The team also strives to improve workforce and population health management for community oncology practices it partners with in Texas and Louisiana.

The initiative surveys all new patients with cancer prior to meeting the doctor the first time, uses predictive analytics performed by Vantage to enhance potential risk factors in SDOH, matches resources to the needs of the patients, and maintains ongoing resource needs assessment.

The community health workers additionally remain part of the patient care team and check in at scheduled intervals, with other metrics, such as quality of life and treatment/appointment adherence, used to assess outcomes for the HOPE program.

“We want to prove the value and total cost of care impact, because that’s the true value that we’re looking for in value-based care. Cost is very important and value to the patient is even more important,” Sabo-Wagner emphasized.

“By the end of the first quarter of 2023, we’d like to have an academic partnership to study how what we’re doing affects clinical outcomes. And then at the end of 2024’s first quarter, AI [artificial intelligence] validation, so that we can expand to additional health stakeholders.”

Current State of Value-Based Care and the EOM
The evening concluded with Stephen M. Schleicher, MD, MBA, chief medical officer of Tennessee Oncology, who outlined the major shift coming in oncology value-based care systems when the EOM takes effect in July 2023.

Despite some reports that described EOM’s predecessor, OCM, as a failure,⁸ Tennessee Oncology was one of several cancer practices that improved significantly from a savings and quality of care perspective, said Schleicher.⁹ However, there were challenges to the model, which he noted will persist with EOM:

Cancer is heterogeneous: Performance and total cost of care by cancer type can vary widely; thus, success is inherently dependent on case mix, especially for smaller practices.

Effect of drug costs: Over time, the oncology therapies have increasingly contributed to total cost of care, diluting the impact of care coordination and efforts to keep patients out of the hospital. Drug costs are more difficult to control; thus, improvements in reducing the cost of things within physician influence—such as hospitalizations—may have less impact on overall performance.

Models trail innovation: OCM and other value-based care models have trouble keeping up with FDA approvals when cost predictions are made. In 2021, there was a record number of oncology drug approvals: 56.¹⁰ Current methodologies to account for new drugs and how they influence the cost of care are not adequate.

“We still did very well and learned a ton along the way. For Tennessee Oncology, OCM was great—it was financially net positive, we got paid MEOS [Monthly Enhanced Oncology Services] just to participate. It gave us a stamp of quality and high-value care from a third party (Medicare), and it provided us a lot of downstream opportunities to participate in other value-based care models that similarly give you that [recognition] in the region,” said Schleicher.

“It catapulted partnerships with other payers, including 2 new narrow networks and 2 more on the way, and it attracted fellows interested in this form of care delivery innovation that otherwise would have never thought to come to Nashville. So, am I glad I did OCM? Yes, [but] it doesn’t mean I’m excited for EOM.”

Acknowledging that he remains unsure whether the EOM is worth pursuing, Schleicher noted 4 key differences compared with the OCM. Most notably, EOM will have approximately half the patients of the eligible OCM population and half the MEOS, he explained, and there’s a narrower and much less favorable “safe zone,” along with mandatory risk from the start of the model.

The other 2 differences show theoretical improvements in adjustments for drug costs, which would better calculate the cost of care for changes in therapy or updates in clinical standards, as well as a requirement for increased reporting on important metrics such as SDOH and patient-reported outcomes.

“EOM is a little more granular with that trend factor novel therapy adjustment, meaning that instead of your practice getting one lump sum, it takes case mix a little bit into it—unclear how much of the benefit that will be,” he said. “The reporting for EOM is good in theory, but it is more work for a practice that is now doing this for a smaller population of patients with way less MEOS coming in.”

Focusing primarily on the first 2 key points, Schleicher said that due to the decrease in eligible populations for EOM after the decision to exclude low-risk patients, the new model will generate approximately 25% overall annual MEOS revenue relative to OCM—a significant difference for a smaller population of patients that may have both financial and operational challenges, especially for practices that did not participate in OCM.

The more stringent mandatory 2-sided risk model for EOM also poses substantial risk for practices. He outlined the differences.

Medicare had the following parameters based on $100 million of anticipated spending on a patient population. Under the OCM, once practices took on 2-sided risk, if they spent less than $100 million, they were in a “safe zone” and would not owe Medicare money. If the practice saved 2.5%, meaning spending was $97.5 million, the practice received money back through performance-based payments and still received MEOS payments.

But, under the lower-level risk tier of EOM, unless a practice saves 2% of the theoretical $100 million predicted spending—meaning it spends $98 million—the practice will owe Medicare money. That means it will not receive a performance-based payment, which does not start until the practice achieves a savings of 4%, meaning total spending is $96 million.

“In the more common situations, if you save 1% in OCM you’re safe, but you still owe money back to EOM for that. And then say you do great and save a full 3%, and that’s after MEOS—so it’s not meaningless—you receive money in OCM, but you’re just safe in EOM,” Schleicher explained. “It’s a way more challenging risk profile, and it’s mandatory risk.”

Given the risks with EOM, pursuing the model will depend on practice geography, payer mix, and competitive landscape, said Schleicher. As the EOM’s launch draws closer, CMS will provide applicant-specific baseline data to each EOM applicant—during April or May of 2023—which will prove vital in determining risk and odds of success with the model.

Ultimately, determining upside of EOM will be practice dependent, concluded Schleicher. Besides a possibly slight financial upside, he said practices will have to see whether there is an intangible return on investment for their brand (eg, stamp of commitment to value), bystander payer partnerships, and education/preparedness for a future if value-based care becomes the standard in oncology. 

References
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9. Jeremias S. US Oncology Network, Tennessee Oncology tout Medicare OCM savings. The American Journal of Managed Care®. November 20, 2021. Accessed February 24, 2023. https://www.ajmc.com/view/us-oncology-network-tennessee-oncology-tout-medicare-ocm-savings
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