OneOncology Physician Leadership Conference: Inaugural Meeting 2022

Exploring the Quest for the “Secret Sauce” in Oncology on an Unequal Playing Field

Jeff Patton, MD, the CEO of the practice network OneOncology, said he had given up the hope of ever seeing reform of 340B, the government program that lets safety-net hospitals buy prescription drugs at discount and then bill insurers the full price, creating a profit stream unavailable to community oncologists.

But in September, The New York Times reported on the case of Bon Secours in Virginia, Patton’s home state. The Richmond-based health care giant had taken advantage of Richmond Community Hospital to quality for 340B, then stripped out the hospital’s specialists and equipment until it was a “glorified emergency room,” with no intensive care unit to care for patients with COVID-19. Meanwhile, Bon Secours’ suburban facilities boomed—all billing off the lucrative drug program.¹

For Patton, the report was a sign that complaints about 340B from the Community Oncology Alliance are finally breaking through. “I’ve gone from hopeless to having some hope,” he said.

Patton related the Bon Secours episode November 11 as he opened the OneOncology Physician Leadership Conference, a 3-day gathering in Nashville, Tennessee, of providers from the 15 practices that make up the growing network, which offers data analytics, clinical pathways, marketing, and administrative support to help community oncology compete in what Patton described as an uneven playing field.

“If health care were a free market, we would have already won,” he said, describing community oncology as the “low-cost, high-quality provider in cancer care.” Powerful forces work in favor of hospitals, from their status a major employer in rural areas to their lobbying clout. Patton explained that these advantages work against community oncology in many ways:

• When health systems buy up primary care physician practices, those patient referrals no longer flow to community oncology.
• Laws requiring price transparency, which should let low-cost providers compete, are hampered by “anti-steerage clauses” that hospitals put in payer contracts.
• Vertical integration, which has gained attention from the Federal Trade Commission, is allowing insurers to make more money from their associated pharmacy benefit manager (PBM). Practices are blocked from using lower-cost drugs or biosimilars due to rebate arrangements.
• Because of 340B, hospitals are financially rewarded for avoiding low-cost options, including biosimilars. Meanwhile, Patton said, the headwinds continue for community oncology, which must absorb 7% inflation and a 4.5% pay cut under the most recent Physician Fee Schedule.²

OneOncology, he said, is helping practices push back against all these trends. “In the past 2 years, we’ve doubled in size—our physician practice number, revenue, and earnings have gone up 50% year over year, despite the ugly forces out there,” Patton said.

A key to OneOncology’s success, he said, is helping practices grow within their markets and gain bargaining power with area payers. (Two OneOncology practices, Tennessee Oncology and Astera Cancer Care in New Jersey, have executed innovative value-based agreements with their respective Blue Cross Blue Shield insurers.) “If you can get dominant or close-to-dominant market share in your local practice [area], you can win,” Patton said.

OneOncology aids practices with physician recruiting, at a time when more medical oncologists are retiring than being trained. Patton highlighted rapid growth at Fort Worth, Texas-based The Center for Cancer and Blood Disorders and on Long Island, with New York Cancer and Blood Specialists.
He said the OneOncology philosophy rests on several core principles: a passion for clinical research, a commitment to value-based care, a data-driven approach that uses measures to drive improvement, and a belief that all discussions start with what makes sense from a clinical perspective.

“We’re doctors and care providers first,” Patton said, highlighting OneCouncil, a physician-led board that drives issues affecting clinical practice.

“We have an incredible value proposition to tell,” he said. Community oncology is decreasing hospitalization and driving down costs—just taking a patient from a hospital to a community clinic cuts infusion costs by two-thirds. Today, the challenge is helping practices meet compliance requirements while maintaining “that Mom-and-Pop feel” that patients prefer and delivering the most innovative treatments.

“That’s our secret sauce,” Patton said.

Lessons from government service. Patton welcomed Adam Boehler, the current CEO of Rubicon Founders; Boehler served in the Trump administration as head of the Center for Medicare and Medicaid Innovation (CMMI). Boehler, who previously founded the home health company Landmark Health, had never pictured himself in government. He was recruited by officials who left CMS after the end of the Obama administration for his ability to “align incentives.” On his watch, CMMI made important adjustments to the Oncology Care Model (OCM) and developed kidney care models.

Patton and Boehler discussed challenges with health care generally and the those that community oncologists face specifically. Boehler described the challenge of creating positive incentives, and then Patton asked about the transition to the Enhancing Oncology Model (EOM), proposed in July as a slimmed-down successor to the OCM. Specifically, Patton asked about the reasons for a yearlong gap between the 2 models; this, he predicted, will cause quality reporting headaches for practices that may want to move from the OCM to the EOM. Is it just politics?

More likely, Boehler said, the yearlong gap is due to the transition between administrations—top staff in the White House are focused on issues such as the war in Ukraine, not CMMI. Beyond that, models are not designed to be permanent fixtures. “If you rely too much on them…if all your economics were based on that, that’s a bad idea. It’s risky,” Boehler stated.

Building around bundled payments makes sense in certain cases, but not in others, he said. In trying to solve problems, it can often make sense to invest in a partner with aligned goals—Patton mentioned full-risk primary care.

Boehler said that primary care groups would be most interested in nephrology and oncology; when he was with Landmark, he noted, “we would always be interested in working with oncologists, because we know where to stop.”

Patton asked what can be done to protect against “perverse incentives” that can exist under fee-for-service, or with situations such as 340B. Boehler offered some thoughts on “natural protections” when capitation is involved, where he said the government’s role is to “aggressively monitor” to protect against bad actors.

Why, Patton asked, is PBM reform so difficult? Why did it seem there was progress on reform, only to see those efforts fade?

The challenge, Boehler said, is a specific risk: that in the short term, a reform effort might lead to higher costs for seniors. “As you can imagine, [higher costs are] not something political administrations like,” he noted. So such an effort would have “to be timed, quite frankly, from a political perspective, before people will take that on. But it was pretty close.” 

References
1. Thomas K, Silver-Greenberg J. How a hospital chain used a poor neighborhood to turn huge profits. The New York Times. September 24, 2022. Accessed November 12, 2022. https://www.nytimes.com/2022/09/24/health/bon-secours-mercy-health-profit-poor-neighborhood.html?smid=tw-share
2. Joszt L. Medicare Fee Schedule expands access to some services but cuts physician reimbursement 4.5%. The American Journal of Managed Care® website. November 2, 2022. Accessed November 12, 2022. https://www.ajmc.com/view/medicare-fee-schedule-expands-access-to-some-services-but-cuts-physician-reimbursement-4-5-


Providers Must Educate Congress, CMS on Reality of Oncology Practice Finances, Patel Says

As CMS moves to implement the Inflation Reduction Act (IRA) as well as the Enhancing Oncology Model (EOM), leading oncology providers must educate both Biden administration officials and members of Congress on how the new law and ongoing efforts addressing payment reform could impact community oncology. Kavita Patel, MD, MS, discussed strategies at the first OneOncology Physician Leadership Conference, held November 11 to 13 in Nashville, Tennessee.

Patel, a primary care physician and former Obama administration policy official, is now a senior policy adviser at Stanford University and a venture partner with New Enterprise Associates. She is also a member of the editorial board at The American Journal of Managed Care®. In Nashville, Patel offered a wide-ranging talk that covered policy issues affecting community oncology. Patel said that although she was “not a fan” of the EOM, which the Center for Medicare and Medicaid Innovation will launch on July 1, 2023, to replace the Oncology Care Model (OCM), “it’s not going away.”

The EOM has been praised by some for retaining and promoting the best features of the OCM, such as patient navigation and same-day appointments to reduce hospital stays. But detractors say it allows no time for smaller practices to ease into value-based care before they face punitive financial models that could shutter a practice over a misstep.

Patel explained that the movement to models that are more heavily focused on downside risk continues a trend that started in the Trump administration—and one that has little to do with politics. The “carrot-and-stick” approach to downside risk can present challenges for oncology practices, which Patel noted offer complex care and need capital to pursue innovation.

Inflation Reduction Act. Describing the IRA as the most significant change to health care since the Affordable Care Act, Patel offered details on the impact and implementation of the new law, which will be phased in over 6 years from 2023 to 2029. Chief elements include a $2000 annual out-of-pocket cap for Medicare Part D, starting in 2025, and price negotiations for 10 high-cost drugs in Medicare Parts B and D starting in 2026, moving to 20 drugs by 2029.¹

“Notice that it’s very clear that physicians or providers are not on here,” she said, reviewing a complex slide outlining the implementation schedule.

In recent years, leaders of OneOncology and other members of the Community Oncology Alliance have raised alarms about the problem of direct and indirect renumeration (DIR) fees, which are caused by a Medicare loophole that allows pharmacy benefit managers (PBMs) to charge pharmacy fees tied to quality measures. For oncologists who manage an in-house pharmacy, these DIR fees are exasperating, because they can show up months or even a year after a drug is prescribed and be tied to measures well beyond the scope of cancer care.

Patel warned that policy makers and members of Congress need more education on the realities of community oncology practice finances, including intricacies like DIR fees. The drugs covered under IRA price negotiations will, by definition, be high-cost drugs, and there could be fallout for practices. “Are you going to get stuck with DIR [fees] coming out?” Patel asked.

Aspects of the IRA seek to shield smaller biotechs from the law’s impact, and Patel warned that pharmaceutical companies, health plans, and PBMs are hard at work looking for ways to protect themselves from losing money. With the downward pressure on out-of-pocket costs for consumers, however, “there is opportunity for actually something good to come out of it,” she said. “If there’s more affordable drug coverage, then there could be a boost in enrollment.”

Some models show that Medicare Part D enrollment could rise from 74% of beneficiaries to 85% or 95%, she said.

Implementation of the law will be key, and CMS is building an office with personnel who have drug pricing expertise. Patel also noted that models from the Congressional Budget Office don’t factor in how the commercial sector will respond to Medicare decisions under the IRA, but oncology practices won’t have a choice. “There are still a lot of questions about what segment of the population this [law] hits, and how this will affect them,” she said.

Patel warned oncologists to demand a seat at the table, so that policy makers gain an understanding of the business side of oncology. “All of this will happen in a very clunky, poorly constructed manner, unless you give inputs and try to say, ‘Let me explain to you what happens when I have a cancer patient who’s on this particular drug that we have that thrive. And here’s why we do this. And here’s what [a] DIR [fee] does. Here’s exactly what the finances are,’” she advised. “That level of understanding never comes into play.” 

Reference
New HHS reports illustrate potential positive impact of Inflation Reduction Act on prescription drug prices. News release. HHS; September 30, 2022. Accessed November 14, 2022. http://bit.ly/3X84CWq


Changing Culture and Finding Champions: Licitra, Arrowsmith Discuss Value-Based Care in Oncology

Implementing value-based care in an oncology practice is a journey, one that demands commitment from every member of the organization and a culture shift that takes time, according to 2 practice leaders taking part in the OneOncology Physician Leadership Conference in Nashville, Tennessee.

Edward Licitra, MD, PhD, who is CEO of Astera Cancer Care, based in East Brunswick, New Jersey, and Edward “Ted” Arrowsmith, MD, of the Chattanooga office of Tennessee Oncology, shared ideas during a panel discussion at the OneOncology Physician Leadership Conference, held November 11 to 13 in Nashville, Tennessee. Sheri Chatterson, MSM, MBA, CFHP, vice president of payer relations for OneOncology, led the discussion.
Chatterson started by asking how practices arrived at value-based contracts, which are needed to implement value-based care. Both Tennessee Oncology and Astera have reached value-based contracts with the Blue Cross Blue Shield (BCBS) entities in their respective states.

“When we do the right thing, we’re always focused on doing the right thing for the patient. The rest of it will follow along,” Licitra said. “We’ll get alignment of incentives, we’ll get better outcomes, we’ll build a better model.”

He acknowledged that value-based care can mean different things to different people. On one end of the continuum are those who start by setting up an oncology medical home, offering Humana’s model as an example. “That’s really the foundation,” Licitra said. “If you don’t build a strong foundation, and if you don’t build a comprehensive value-based care home that evolves over time and gets better based upon all the experiences that happen…you really don’t have much.”

On the other end of the continuum, value-based care moves toward capitation, which could be “transformational,” said Licitra, but extreme care is required. Shared savings models, including the Oncology Care Model (OCM), are retrospective in nature; the OCM started as a 1-sided risk model to train practices and evolved into a 2-sided risk model.

Arrowsmith said that value-based models have evolved because cancer care has become expensive, “and there’s not that enthusiasm for just writing a blank check to pay for whatever it is that you do.” Payers, he said, want to see constructs such as pathways to bring more standardization to care, to drive down costs, and to prevent unnecessary emergency department (ED) visits and hospitalizations. Tennessee Oncology was able to reach a contract with BCBS of Tennessee, the state’s largest payer, which is “toward the beginning of the continuum,” and requires certification of lessons learned over 5 years and proof of quality care.

From there, Arrowsmith said, Tennessee Oncology was able to “get into the room” with BCBS to negotiate a contract that spells out what the practice can and cannot control, specific targets, and margins to beat.

Chatterson asked Licitra and Arrowsmith about the nature of relationships with vendors under value-based care.

Licitra emphasized the need for partnerships. “Unless you have a willing partner who is ready to sit down, roll up [their] sleeves, and actually work together toward a common objective, none of these things ever work,” he said. In New Jersey, Astera was fortunate to have a willing partner in Horizon BCBS, and the 2 entities started 4 years ago working together on cancer episodes. “We started out with medical oncology, then added radiation oncology and breast surgery,” Licitra said.

The episodes had to be well defined, by certain lengths of time, and Astera had to be able to construct the episode for each patient who “didn’t have to pay attention to fee-for-service.”

Licitra said that payers like this approach because it offers a deeply discounted rate compared with similarly bundled services. “It actually reduces a lot of the burden on both the patient and the physician, because they’re not worrying about getting things approved,” he noted.

Arrowsmith added that value-based contracts can be customized to highlight a practice’s strengths and minimize its weaknesses. Whereas Astera has a breast cancer model that includes its breast cancer surgeons and radiation centers—and can include lower charges for those services than the payer would see from a hospital—Tennessee Oncology leaves those items out.

Next, Chatterson asked what it takes to change a practice’s culture.
“Culture isn’t one big thing you do,” Arrowsmith said. “It’s a thousand little things you change over time.” Doctors and nurses want to do the right thing—it’s about thinking of ways to incentivize all the little things that improve care and patient experience.

It’s not simple, Licitra said. “If it were just a handful of things, everyone would do it,” he pointed out.

The shift in mindset, Licitra pointed out, goes beyond optimizing clinical variables to a change in approach, which means much more than doing something inappropriate. “Once you enter value-based care arrangements, the physicians have to think about the world of medicine very, very differently,” he said.

And it’s not just the physicians: The triage nurses, the chemotherapy nurses, and the rest of the staff all must think through the consequences of what their decisions might mean that day, as well as several days or months ahead. “It takes a lot of work to make sure that you continuously provide physicians with data,” said Licitra. “You have to provide them with reliable data, because they all say that your data are wrong. Provide us with reliable data and make sure that before you go into the meeting, that your data are actually correct.”

So, where does a practice begin if members want to venture into value-based care?

“Find a champion—or a few champions—for value-based care,” Licitra replied. Without that lead physician, administrator, or pharmacist who is passionate about making the culture change and the execution work—about doing the right thing—it will be hard to evolve.

“You think about it as kind of a challenge, because a lot of work has to actually happen to be successful,” continued Licitra. “Without the proper leadership and the proper champions for it, I think it’s tough to do.”

Arrowsmith suggested identifying the key levers, such as keeping patients out of the ED, which can make a significant difference. And, he said, “Don’t give up.”

Some ideas that practice members might think are terrific might fall flat with payers, Arrowsmith said, but it’s important to keep talking. It took Tennessee Oncology 5 years to reach their agreement with BCBS of Tennessee.

The physicians said that starting with a framework the payers are already using and adapting an idea to fit that model works much better than presenting something completely different. And once a practice has implemented the first model, Licitra said, “the rest are a lot easier.”