Population Health and APMs

Andrew L. Pecora, MD, CPE: There’s a lot of conversation about the importance of population health, and if you look at a population of patients, however you codify them, there’s people that are treated ideally, there’s people who get too little care, and there’s also people who get too much care. And the people on the end of those spectrums don’t get the desired outcome. Either you’re wasting money and doing harm, or you’re not doing enough and you’re doing harm, even if you’re saving money.

So we’ve been working a lot on finding the “Goldilocks Zone”—not too much, not too little; just right and looking at what we do as it affects total cost of care. So, one of the problems with the insurance industry is it’s unlike the mortgage industry. If I buy a house, I don’t pay for it all at once. I actually amortize it over a period of time. That’s my mortgage. So, like in hepatitis C, when we had these drugs come into the market that cure patients and you take them for a very short time, but they’re expensive, that’s very hard (if you’re an insurance company) to figure out how you’re going to do the actuarial analysis. Now we have immuno-oncology drugs, that we’re going to get to a little bit later, that are changing the whole paradigm of how we think about cancer. So, what thoughts have you given [in regard to] how do we enable and support spending more money up front when it can save a lot of money long-term? And how do we do that from an insurance perspective? How do we do that from a clinical perspective?

Rena M. Conti, PhD: Well, that’s the wonderful part of having a government as the payer. Government doesn’t need to make annual revenue or save a certain amount of money over a very short period of time. Instead, they can invest in population health now and wait for the payoff in the future. Part of, I think, what is happening with the excitement over some alternative care models, particularly medical homes and accountable care organizations (ACOs), is really putting physicians and medical practices in that same seat of really wanting to invest in preventive care and types of care that provide long-term benefit and give them a financial incentive to do so.

I think that it’s remarkable that Medicare has waited this long in oncology to start thinking through, “Okay, what is the investment that we’re getting that is up front? What kinds of payoff does it have in the future?” We want to make sure that patients who have cancer are going to [continue to] be able to work and care for their families. That’s an investment that pays off in many different ways over time. We want to give providers the same incentive to think of their patients as a whole and get them financially cognizant of those type of long-term payoffs, as well.

Andrew L. Pecora, MD, CPE: Great.

Brenton Fargnoli, MD: From a clinical perspective, for the patient, it’s their health and their life for the duration. Maybe one year they’re [the patient] with Aetna, another year they switch and go to Cigna, and the third year they’re on Medicare. There’s a different entity footing the bill, if you will. But I think, as you mentioned, the point of this all is “the patient.” [We need to remember that] this is [about] the patient and it’s a choice for their duration. It’s not [just] about what the impact is going to be today, but also the impact for the single patient for the next 20 years. So I think that’s one key component.

I think the second key component is that drug prices are part of the cost, [but] they’re not the entire cost. When you look at that entire patient journey, certainly there’s a piece around selecting the right treatment. But then after that, are we identifying the patients to [whom we need to] provide enhanced care management to prevent hospitalization? Then, toward the end of life, are we providing enhanced palliative care to increase quality of life and decrease total cost of care? So, taking that total view, I think, is going to be important, as well.

Andrew L. Pecora, MD, CPE: I’ve been involved with government recently in an advisory role and I’m pleased to say that the argument of looking at total cost of care is starting to win [over] looking at unit-based care. Because for a short period of time, the laser beam focus was that drugs cost too much— without any consideration of what those drugs did to total cost of care, as one example.