Paying for Cancer Care Differently: A Look Into the Future

Changes are coming fast in community oncology: Medicare’s Enhancing Oncology Model (EOM) is now more than 5 months old, but multiple commercial models operate alongside it. Payers are buying up primary care practices, disrupting referral relationships that took years to build. Employers see cancer care as a big-ticket item that must be brought under control.

Technology offers opportunities for patients to report symptoms such as rashes or fevers before they lead to a hospital stay, but these systems cost money. And today, quality reporting now includes addressing social determinants of health (SDOH). This puts practices on the spot when a patient with cancer says they don’t have food or a place to stay.

If an independent practice had to manage all this alone, it might be overwhelming. Members in The US Oncology Network (The Network) had a chance to look into the future and gain skills they will need to thrive during the 2023 Payer Transformation Summit, held September 27-29 at the OMNI Hotel & Resort in Atlanta, Georgia. McKesson, which supports The Network, hosted approximately 100 leaders from about 20 practices for in-depth presentations that included:

• what the future risk landscape will look like,
• what CMS and other payers will require in areas such as health equity and SDOH,
• how practices make the most of electronic patient-reported outcomes (ePROs), and
• how practices can negotiate effectively with payers.

Wilfong

Hammonds

“We’re going to be really delving into how we're paying for cancer care differently, something that is of increased importance to both Medicare and commercial risk-bearing entities,” said Lalan Wilfong, MD, senior vice president of Payer and Care Transformation for The Network, to kick off the second day of the meeting. As entities that refer patients take on more risk themselves, Wilfong said during one discussion, “We have to be prepared as a network to engage.”

“The US Oncology Network has been experiencing steady growth in recent years, now with more than 2400 providers delivering care in 30 states,” said Jason Hammonds, president of The Network. “Our vision is to be the leader in providing premier oncology care, and we’re delivering on this in multiple disciplines, including setting up practices in The Network for success in value-based care.

“As we support the largest network of independent, community-based providers, we are embracing models like the EOM so practices can deliver quality outcomes at a sustainable cost. I’m proud that 70% of the providers in The Network are participating in the EOM, which equates to over 50% of the total participants in the nation.”

Speakers at the summit highlighted how solutions will have some common elements, but they must also be tailored to individual markets and to partners’ needs. For example, Angela Storseth, director of Government Relations & Public Policy for The Network, discussed how laws governing value-based arrangements vary by state.

Data remain a challenge. During the discussion, “Preparing for Future Risk Arrangements,” panelists described the limits of data sets and the labor-intensive task of cleaning them up for analysis. Shannon Hough, PharmD, senior director of Clinical Programs for The US Oncology Network, said, “In my core, I wish we had a great data-driven way to compare the value of therapies.”

By the final day, practice leaders heard scenarios on how to negotiate from Haroon Kalam, PhD, of the Broad Institute at Harvard Medical School, and took part in small-group discussions on payer negotiations, ePROs, and SDOH. The summit concluded with hands-on lessons in how to use quality reporting platforms, with opportunities to speak with developers who were on site.

Understanding the New Risk-Bearing Landscape

Rahul Sangal, who is senior director for Provider Strategy, Specialty Practices at McKesson, described a “changing of the guard” in the operating model for primary care providers (PCPs), which he said has important downstream implications for providers and patients alike.

“We’ll start with the most important question in any of these kinds of talks, which is: why should you care?”

Oncologists should understand what’s happening in primary care ownership because it’s part of a bigger picture, Sangal explained. “Primary care is the first step in a process, where ultimately these payer platforms will look to manage the patient’s journey end to end, by employing and operating specialists across the patient’s journey,” he said. “So, while we’re starting in primary care, the end goal impacts every one of us—and multispecialty in general.”

Already, he said, Bain Capital estimates that 30% of the $250 billion primary care market will be held by “non-traditional players” by 2030¹, which include payer-backed platforms as well as entities such as Amazon.

What draws payers to these investments? Sangal said for payers, it’s about driving operational efficiencies; providers, meanwhile, are attracted by financial incentives and the chance to free up time, so they can focus more on patient care. Physicians, he said, “can see their compensation increase, reduce the operational and administrative burden of their practices, and provide a more integrated care experience for their patients.”

As good as these arrangements look for PCPs, the payer incentives are even greater, Sangal explained. Payers are creating arrangements that allow the 2 sides to share savings, “but more importantly, by influencing how these PCPs operate, documenting more chronic conditions that lead to higher capitated payments, they're able to realize significantly higher premiums.”

Although patients “are largely along for the ride,” Sangal said, “there do seem to be benefits…in the form of integrated care that leads to better outcomes, particularly for patients with chronic diseases.” It’s a rare case of incentives being aligned for all, he said.

Targeting Medicare Advantage (MA) is especially attractive to these payers, because documenting chronic conditions brings greater reimbursement under a capitated model, and the payers’ PCP platforms emphasize this documentation, Sangal said.

“In fact, the financial incentives here are so significant that we've seen the number of Americans with at least 1 chronic condition documented since 2017 grow by 20%, and the number of Americans with 3 or more chronic conditions has grown by 56%,” he said. “It's not that we're that much sicker, it's that we're getting to that much better with writing it down.”

He expects this growth to continue, as MA now accounts for about half the Medicare population; by 2030, it’s projected to be about 70%.² “Of course, that model depends on patients benefitting from the experience,” he said. And it appears they do: most risk-sharing arrangements have a 90% approval rating from patients, because they offer services that patients use—such as vision or fitness programs.

Sangal noted, however, not all the transactions in these arrangements are in primary care—increasingly, they were in multispecialty care. Ultimately, this will be the area of expansion; oncology has already been a target in some markets, although Wilfong later noted that the track record has been mixed.

The goal for payers, Sangal said, is a global accountable care organization model, where the payer entity manages all aspects of care, with the hope of ensuring better quality and improved medication adherence.

“It helps to emphasize just how much investment payers have already made in vertical integration. All the major players have some level of investment or assets in most aspects of care delivery,” he said, noting the entities that combine a payer, a pharmacy benefit manager or a specialty pharmacy, and provider groups. “Specialty care is going to be next in their areas of focus.”

Where does this leave independent oncology practices?

Embracing value-based care has shown the importance of taking ownership of care delivery, Sangal said. But doing so at scale requires technology and data to achieve savings; for payers, Sangal sees this as a “limiting factor.”

Payers are interested in whether a practice can demonstrate cost savings, and if a practice can do so, a payer may not see the need for a full-blown acquisition in the more challenging specialty areas. An Optum-owned oncology clinic recently closed in the Dallas-Fort Worth, Texas, area,³ Wilfong noted, and another site has experienced turnover. “Oncology is really hard,” he said.

Said Sangal, “From a Network point of view, what that means is that we have to be prepared for those changes coming down the marketplace, whether it's next year, 3 years, 5 years,” Being prepared means practices must show they can work with payer platforms and “demonstrate the value delivered to patients.”

“If we're able to show payers similar cost savings, similar integration and care without the headache that comes with buying up practices, integrating practices, changing technology solutions, we can get a win-win situation for ourselves, for payers and for patients as well,” Sangal said. “Because if we're able to document and prove the value we deliver, then we can continue to provide the best care for patients and be part of that journey.”

A Cancer Care Solution That Delivers Quality, Cost Control, Collaboration

As employers look for ways to control health care costs, solutions such as bundled payments have emerged as a method to bring more predictability to spending. Lora Markley, regional director of Managed Care for The US Oncology Network, moderated a panel that examined a bundled payment agreement between Carrum Health and Texas Oncology, which was reached shortly before the meeting began.

Carrum Health, featured in Evidence-Based Oncology in February,⁴ works largely with self-insured employers to offer prospective bundled payments in traditional high-cost care areas. Under this concept, Carrum takes on the direct-to-provider contracting and case management, while also selecting “centers of excellence;” these providers have track records of offering guideline-concordant care, which evidence shows achieves better outcomes while holding down costs. In a commentary co-written for EBO, Carrum CEO Sach Jain, MBA, said that the company’s renegotiated treatment bundles resulted in savings of 20% for employers, giving companies financial incentives to offer “appropriate, evidence-based care, proactive symptom management, and cost-effective treatments,” such as biosimilars.⁴

Saulet

Brewer

Deirdre Saulet, PhD, Market VP for Oncology, Carrum Health, said since Carrum began bundled payments in oncology in the first half of 2022, “Interest has been overwhelming.”

Over the past 2 years, she said, cancer has overtaken musculoskeletal conditions as the top cost driver for large, self-insured employers. “This was a real moment of reckoning for them,” Saulet said of employers, many of whom had previously shied away from taking on cancer care costs. Today, these same employers feel compelled to make sure their employees are finding high-value providers.

Travis Brewer, vice president of Payer Relations at Texas Oncology, shared how he’d seen traditional payers bring value-based arrangements into the market, only to watch them “crash and burn.” He was familiar with Carrum Health’s work in cost control in orthopedics, so he jumped at the chance to get Texas Oncology involved in an oncology bundle. “Employers love them,” Brewer said. “I was all in.”

Saulet said Carrum’s program creates an opportunity to not only achieve savings but to also educate the market about value. “What does guideline concordant care mean? What are clinical pathways? Why does care management matter so much?” she said.

Finally, she said, employers are very motivated by their employees’ experiences with financial toxicity. “It is our goal to lessen the financial burden of a cancer care diagnosis,” she said. When employees use center of excellence providers, their out-of-pocket costs are waived, and they receive a stipend for non-medical costs such as transportation or child care.

Markley asked whether Carrum was focused on common cancer diagnoses. Saulet said the first cancer bundle is in non-metastatic breast cancer, which is the most common diagnosis in the commercial population; upcoming bundles include colorectal, prostate, and other gynecological cancers.

“Bundling takes time,” Saulet said. “This is not for the faint of heart. So, we're starting to think about what other value-based models and mechanisms can improve access and increase the number of patients we're able to treat.”

How does Carrum select providers as centers of excellence? To some degree, these should match where employees live, Saulet said, but that’s not the only factor: the most important criteria are the “willingness and appetite” to participate in value-based care; a commitment to quality across all sites of care, as demonstrated by metrics reporting; and patient satisfaction, which also must be reported.

Carrum representatives go in person to meet the providers who will be taking care of the breast cancer patients, Saulet said. They ask questions patients would ask. “What's the support that's going to be available to me?”

Markley noted that this model has 2-year episodes, unlike typical episodes in other models that run for 6 months. She asked Jenny Fernandez and Gunjan Sharma, both senior business intelligence analysts at McKesson, to discuss model specifics and the collaboration it took to reach agreement.

Fernandez described both external collaboration between Carrum, The Network and Texas Oncology, as well as internal collaboration within various teams (Payer Solutions, IMPACT Analytics, Revenue Cycle, Care Transformation, Finance, etc.) within The Network as a recipe for success. As for working with Carrum, “They were so helpful…especially given that this is a very unique program. They were always available to discuss and brainstorm ideas, kept the model flexible and were receptive to proposed tweaks,” she said. Internally, Fernandez said it was important to have the right teams come together and the right data to evaluate the model and its impact on treatment, payment and operations at the practice. Brewer’s familiarity with Carrum was also important, she said.

Sharma said working with a 2-year breast cancer episode means “We are looking not only at the duration of active therapy and chemotherapy/radiation services, but we're also including the supportive drugs and survivorship period, which is critical.”

Brewer said Carrum’s approach differs from traditional payer programs, which fail because “they whack you over the head with what they think is the right model—and there’s no wiggle room to customize it. The best part of what we’ve set up for Texas—and what the other Network practices will have the opportunity to do—is to take a structured program and tweak it to make sense for the practice. It’s structured, but it’s also flexible enough to pivot,” he said.

“This is a collaboration in the truest sense.”

Growth in Medicare Advantage: the Payer Perspective

With half of Medicare beneficiaries now enrolled in MA,⁵ understanding the basics is essential—and Humana’s Lily Pham, MD, MBA, regional vice president, said it’s likely oncologists have seen their membership panels shift. Humana has fueled that growth: the insurer now has more than 5 million MA members and saw a 13.7% enrollment jump coming into 2023.⁶

Pham reviewed what each “part” of Medicare does: Part A is hospitalization, Part B is outpatient care, Part C is MA, bundling hospital, outpatient, and drug coverage; and Part D is prescription drug coverage.

“The reason that Medicare Advantage has gained popularity in the past decade or so is we offer benefits our original Medicare does not,” Pham said, as she displayed a list of benefits that the plans can offer. “I'm not saying that every single one of these benefits is available on every single plan that we offer,” but the benefits can be tailored to specific plans and regions. Transportation is especially popular; so are healthy foods.

There are also special needs plans for specific populations, including patients with chronic disease—HIV, chronic obstructive pulmonary disease, or congestive heart failure—as well as plans for those who are also eligible for Medicaid. For those who are dually eligible, plans are state specific, with individual states supporting members through copays and premiums.

A new benefit offered in some states serves members in long-term institutionalized care. “The goal is to keep them in that long-term care facility,” Pham said. Instead of transferring those patients to a hospital, the plan is to work to have a coordinating care team keep the patient out of the hospital during routine situations, such as a fever, to avoid infection.

Premium dollars for the plans flow to Humana from the government, and Pham’s team work on utilization management, such as ensuring inpatient care meets medical necessity or that medications that are requested are on pathway.

It’s also very important to keep Medicare Star ratings high, she said. “It allows for our customers to look at different MA plans and compare them apples to apples,” Pham said. “I am really proud to say that in 2023, about 96% of our membership within Humana are in plans with 4 stars or greater [on a 5-point scale]. And 66% of our members are in plans 4.5 starts or higher. We worked really hard to get to that point.”

Investments in transportation services or exercise programs help with Star ratings, Pham said, but “What's really important in the Star ratings, and all of the work we do as an MA plan is our partnership with our providers. It's the key to our success.”

Everything in the Star ratings must be documented for CMS, including HEDIS measures (Health Effectiveness Data and Information Set). Supplemental data comes from providers, and patient safety measures are based on claims data. Pham went into detail about how patient satisfaction data and clinical data are recorded, to show that chronic conditions are being monitored, medication reminders are happening, and reimbursement adjustments are occurring based on each patient’s condition.

“The intent is to create coordinated care—a collaboration between the whole plan [and] the providers to ensure that the patients and members are getting the care they need,” she said. When that happens, patients avoid hospital stays and the cost of care is lower. “It’s a win-win for everybody.”

Evidence Supports Electronic Patient-Reported Outcomes

If a new cancer therapy improved overall survival by 5.2 months compared with the standard of care—with no additional toxicity, and more likely less—its sponsor would herald this innovation, and FDA would quickly approve the drug.

Basch

Hudson

Yet it took a pandemic for technology-driven patient monitoring to really take off in cancer care, after a survival advantage seen in 2017. That’s when Ethan Basch, MD, MSc, of the University of North Carolina School of Medicine, presented findings from a study of electronic patient reported outcomes (ePROs) during the American Society of Clinical Oncology (ASCO) plenary session.⁷

Basch acknowledged that concerns about cost and upfront work are real, but he said oncology practices should embrace ePROs as a positive innovation because they allow clinicians to deliver better care.

Now the chief of the Division of Oncology and physician-in-chief at North Carolina Cancer Hospital within UNC School of Medicine, Basch said evidence including the 2017 study has been accumulating for 20 years in more than 300 papers. As he told practice leaders, with ePROs now included in the EOM, “The writing is on the wall.”

Yet Basch said ePROs have experienced resistance at each step of development. There are practical issues with implementing ePROs, whether or not the practice is taking part in the EOM, but he said the time and resources spent monitoring patients is saved elsewhere in the care journey.

“It goes without saying to this audience that symptoms are exceedingly common among patients with cancer. Almost 100% of patients with cancers receiving systemic therapy have symptoms that interfere with their functioning and their quality of life. Symptoms are a very common cause of avoidable hospitalizations and [emergency department] visits, and therefore poorly controlled symptoms are a major contributor to cost of care,” Basch said. “Poorly controlled symptoms can preclude treatment; poorly controlled symptoms can shut down a clinic in the middle of the day when somebody comes in.”

But historically, he said, practices have not been proactive in symptom management—once a clinic visit ended, that patient was off the radar. That raises the question about what happens when a patient has symptoms that the clinic team should know about, but in the past has not heard about until the patient ends up in the ED or perhaps at the next appointment, if the patient remembers to say something.

“Patients often are reluctant to contact the practice. And also, it's very hard to get through to us,” Basch said. Some patients have told him they believed their symptoms were just a normal part of having cancer.

The solution? A system that sends patients electronic “reminders” in text messages, emails, or automated phone calls, to proactively ask them about symptoms commonly seen in cancer; patient responses would then trigger alerts to navigators, whose response would vary depending on the nature or severity of the symptom.

If the patient has a severe or worsening symptom, then we can generate reports showing the trajectory of symptoms over time and look at it [during] visits with our patients,” Basch said. “And being on top of how our patients are doing, interestingly enough, will bring us closer to our patients.”

Thus, instead of technology being a wedge between doctor and patient, the technology helps the issues most important to rise to the top of the discussion, Basch said. “This is a much more proactive approach,” he said. “We're on top of things in real time.”

The first such reporting system was used in 2001; it adapted the Common Terminology Criteria for Adverse Events (CTCAE) from the National Cancer Institute. “There were no iPads or new iPhones, so clinics would be doing this on industrial tablets,” Basch said, showing examples of early reports from this era. Today, such a report might flow to the electronic health record, but it got the job done.

“There were skeptics,” Basch said. The first level of doubt was that this seemed like a good idea, but it wasn’t feasible—patients simply wouldn’t do it. So Basch and his team produced studies from both academic and community practices that showed 60% to 70% of patients would report symptoms in a well-executed program.^8,9

Then, the skepticism shifted to, “Do we really need our patients to do this? Our teams know our patients.” One study over a 3-year period found that patients have symptoms that are missed about half the time, Basch said; a 2019 retrospective analysis evaluating patient vs clinician assessments also found patients reported more symptoms than clinicians uncovered.¹⁰

Finally, the skeptics asked, “Does it really matter clinically?” And that’s when the study of 766 patients with solid tumors receiving cytotoxic chemotherapy was launched, with patients randomly assigned to usual care or use of ePROs to report their symptoms. Patient went to the nurses whenever a severe or worsening symptom was reported, Basch said. Median follow-up was 7 years; at that point, but two-thirds of patients had died. More patients in the ePROs arm reported significant and meaningful quality of life benefits.⁷

“We then looked at emergency room visits and hospitalizations and found that compared to standard care, 70% fewer patients in the ePRO self-reporting [group] visited the emergency room, with durable effects over time, and we found the same effect size for hospitalization.”

The OS result attracted the most interest, Basch said. Patients in the ePRO group had median survival that was 5.2 months longer than those in the usual care group, and nurses acted on 77% of the alerts. Symptom control was improved in the ePRO group, so patients could stay on treatment 1.9 months longer.⁷

“These results have subsequently been duplicated in other studies,” Basch said, citing both in international studies and in studies with community practices; when paired with improved navigation, ePROs reduced hospitalizations and grade 3 toxicities, helped patients stay on chemotherapy, and improved patient satisfaction. He cited a paper co-authored with Texas Oncology’s Debra Patt, MD, PhD, MBA, which outlined best practices for improving ePROs, based on the practice’s implementation in partnership with Navigating Cancer.¹¹ ASCO’s APC4 initiative,¹² a certification that many see as an alternative for practices who do not enroll in the EOM, will include ePROs, he said.

Implementation. Basch and Kathryn Hudson, MD, a hematologist/oncologist who is director of survivorship at Texas Oncology, then discussed implementation issues for ePROs, including the paper on the “Texas Two-Step” program, which first measured patient preferences for ePRO enrollment and then assessed clinical utility of the program.¹³ Basch and Hudson addressed staffing issues around ePROs—it takes hard work and manpower to set up a system that responds to patient input, but time is saved downstream because emergencies and disruptions are prevented.

“Our program began in 2020, and it has continued to evolve,” Hudson said. Nursing leadership must be engaged—in fact, Hudson recommends that nurses primarily run the program with physician guidance.

As the use of ePROs evolves, she said, “We’ll be able to target specific surveys for different groups of patients at specific points in time in between visits.” This way, she said, patients will be answering surveys that are applicable to their clinical situation, maximizing its impact. Over time, for example, Texas Oncology has tailored the program to include a “decline-a-call” feature, which allows patients to report symptoms only; this limits the number of outgoing calls.

Although it can be hard to pick up in claims data, Basch said, ePROs do allow practices to quickly catch adverse reactions to immunotherapy and quickly make dose adjustments. “We have heard that there’s actually a fair amount of dose modification based on poorly controlled symptoms,” he said. According to Hudson, “We have found that patients who are entering their ePROs do stay on therapy longer.”

Lack of reimbursement has been a barrier to implementing ePROs. In fact, many practices cited this in their decision to stay out of the EOM, as the Medicare payment model would require their use without any guarantee of compensation. Basch and Wilfong referenced a paper featuring the outcomes of “Texas Two-Step,” presented at the ASCO Quality Symposium in late October, which found that Texas Oncology’s program produced a 39% reduction in hospitalizations and a $1146 per-patient, per-month average savings.¹⁴

If practices can demonstrate benefits of ePROs from a payer standpoint—both in reducing costs and improving quality of life for patients—they have a greater chance of winning the argument on reimbursement, Wilfong said. Keys to success, Basch and Hudson said, are finding the right tools, having ePRO champions at the practice level, and continuing to embrace change. Basch said a train-the-trainer approach is essential given staff turnover, and Hudson said Navigating Cancer has been “a great partner” with Texas Oncology. “We’re always talking about how we can improve the platform to suit both our needs,” she said.

References

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2. McWilliams JM. Don’t look up? Medicare Advantage’s trajectory and the future of Medicare. Health Aff. March 24, 2022. doi: 10.1377/forefront.20220323.773602

3. Hatton R. Optum undergoes layoffs: what ASCs should know. Becker’s ASC Review. August 14, 2023. Accessed October 14, 2023. https://www.beckersasc.com/asc-news/optum-undergoes-layoffs-what-ascs-should-know.html

4. Stadler M, Jain S. To expand access to cancer expertise, collaboration is key. Am J Manag Care. 2023;29(SP2):SP149.

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6. Japsen B. Humana sees growth of at least 625,000 Medicare Advantage members this year. Forbes. February 1, 2023. Accessed October 14, 2023. https://bit.ly/46yc41s

7. Basch E, Deal AM, Dueck A, et al. Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment JAMA. 2017;318(2):197-198. doi: 10.1001/jama.2017.7156.

8. Judson TJ, Bennett AV, Rogak LJ, et al. Feasibility of long-term patient self-reporting of toxicities from home via the Internet during routine chemotherapy. J Clin Oncol. 2013;31(20):2580-2585. DOI: 10.1200/JCO.2012.47.6804

9. Dueck AC, Mendoza TR, Mitchel SA, et al, for the National Cancer Institute PRO-CTCAE Group. Validity and Reliability of the US National Cancer Institute's Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). JAMA Oncol. 2015;1(8):1051-1059. doi: 10.1001/jamaoncol.2015.2639.

10. Atkinson TM, Dueck AC, Satele DV, et al Clinician vs patient reporting of baseline and postbaseline symptoms for adverse event assessment in cancer clinical trials. JAMA Oncol. 2020;6(3):437-439. doi: 10.1001/jamaoncol.2019.5566

11. Basch E, Rocque G, Mody G, Mullangi S, Patt D. Tenets for implementing electronic patient-reported outcomes for remote symptom monitoring during cancer treatment. JCO Clin Cancer Inform. 2023;7:e2200187. doi: 10.1200/CCI.22.00187.

12. Gamble B. Enhancing Oncology Model. Presented at: Association of Community Cancer Centers. November 18, 2022. Accessed October 14, 2023. https://bit.ly/3FmmJAx

13. Patt D, Wilfong L, Hudson KE, et al. Implementation of electronic patient-reported outcomes for symptom monitoring in a large multisite community oncology practice: dancing the Texas two-Step through a pandemic. JCO Clin Cancer Inform. 2021; 5-615-621. doi: 10.1200/CCI.21.00063.

14. Patt D, Patel AM, Bhardwaj A, et al. Impact of remote symptom monitoring (RSM) with electronic patient-reported outcomes (ePRO) on hospitalization, survival, and cost in community oncology practice: The Texas Two-Step study. JCO Oncol Pract. 2023;19(suppl_11):abstr 569. DOI:10.1200/OP.2023.19.11_suppl.569