Value-Based Care Expert Discusses How COA Has Advanced the Role of the Physician Advocate

Twenty years ago, the Community Oncology Alliance (COA) emerged from a crisis: Proposed changes to reimbursement formulas contained in the Medicare Modernization Act of 2003 (MMA)¹ threatened the financial health of oncology practices, and physicians banded together to take their case to Washington, DC.

As COA evolved, the group advocated not just for providers and practices but also increasingly for patients. Today, for example, COA is deeply involved in the current debate over several key policy issues that impact the care of individual with cancer, including the role of pharmacy benefit managers in determining both the cost and availability of cancer therapies.²

The concept of physician advocates taking an active role in the health care policy arena may seem outside the normal job description, but it’s hardly new. To discuss this trajectory and how it applies to COA, Evidence-Based Oncology (EBO) spoke with A. Mark Fendrick, MD, professor of internal medicine and health management and policy at the University of Michigan and director of the Center for Value-Based Insurance Design (V-BID Center).³ With longtime collaborator Michael Chernew, PhD, Fendrick originated the concept of value-based insurance design^4,5; they are co-editors in chief of The American Journal of Managed Care.

EBO: The role of the physician advocate in the policy arena is not new; the literature on the topic goes back decades.⁶ As a physician who has been involved in the policy arena throughout your career, how do you see that the role of the physician advocate has evolved?

Fendrick: The journey for me started over 45 years ago when I took an introductory health care systems class as a pre-med student at the Wharton School at the University of Pennsylvania. I became interested in social determinants of health, healthcare disparities, and the financing of medical care delivery. With a better understanding these many challenges, I pondered not becoming a clinician and considered playing a role focused more on population health. My mentor at the time, Bernie Bloom [PhD], advised, “You have to become a clinician, because they make all decisions regarding health care policy.” I’m sad to say that with the pronounced shift over the past 5 decades to an emphasis on ”how much” we spend on health care as a substitute for ”how well” our dollars are spent, Bernie was probably wrong, as many of the key decisions regarding health care transformation in the United States are made by nonclinicians.As key decisionmakers pay less attention to what is truly best for our patients—instead of the bottom line—is why we all have to advocate for an enhanced role for clinicians and their patients as we move these important deliberations forward.

A really good example of the lack of the clinicians’ role in policy making is the well-publicized price negotiations for prescription drugs in the Medicare program under the Inflation Reduction Act (IRA).⁷ As you look through all the CMS decisions and guidance on the negotiation process, you’ll see minimal opportunities for clinician involvement. I can think of no better constituency that understands the unmet clinical needs of individual patients and challenges faced by underserved populations.

EBO: You were heavily involved in crafting the value-based care elements in the Affordable Care Act.⁸ Why was it so important for practicing physicians to be involved in developing that legislation, which affected how everyone is reimbursed—specifically through the formulas for value-based care?

Fendrick: I have long felt that it’s essential for policy makers and decision makers to have a better understanding of what it means to sit across from an individual patient. The understanding of ‘clinical nuance’—the idea that the clinical benefit derived from a specific medical service—whether it be prevention, treatment, or a procedure—depends on who is using it, who is delivering that service, and where it’s being delivered—is a concept that my colleague Michael Chernew and I have developed over the years.Clinicians are very well suited to determine when a service will benefit patients (and should be reimbursed) and when it does not (and should not be).

It’s also important for policy makers to realize that they not focus not only where the puck is, so to speak, but also where the puck is going to be. Given my longstanding interest in identifying policies that enhance equity and reduce disparities, I feel that it’s been very important to reinforce to key decision makers the issue of unmet needs—not just exactly what’s happening today, but the problems we currently face and potential solutions that are needed to make future populations healthier.

EBO: We’re talking now specifically about the formation of the Community Oncology Alliance, which occurred as a response to a piece of legislation, the Medicare Modernization Act of 2003.¹ Community oncologists felt their practices were threatened because this legislation would have altered their reimbursement mechanism. In what ways did that episode serve as a model for physician engagement?

Fendrick: My dream medical care delivery scenario is that after clinician and their patient sitting deciding together that a particular service or set of services might improve their health, it is easy, not hard, for the clinician and the patient to receive that service. For several reasons that is currently not the case, as there are barriers for both patients and clinicians to deliver recommended care. And when these hurdles are added to the challenges that the MMA brought about two decades ago—it becomes obvious that clinicians and patients needed to organize. In my opinion, the Community Oncology Alliance is an exemplary organization in its ability to bring together community oncologists and their patients to identify their priorities and craft implementable solutions to achieve those goals.

EBO: So how has COA’s model for physician and now patient engagement—because they’ve gotten patients increasingly involved over the years—worked to move the needle on value-based care from your perspective?

Fendrick: The Community Oncology Alliance, including their exceptional leader Ted Okon, an amazing staff, and dedicated members, has really done a terrific job “walking the walk” on how physician and patient engagement can bring about meaningful change in terms of access and affordability to evidence-based oncology services. In addition to their fundamental work in enhancing the care of individuals diagnosed with cancer, I have seen how that their efforts and best practices have been used by other professional organizations. Mimicry is clearly the best form of flattery.

EBO: Both the V-BID Center and COA strive to be bipartisan. Why is this important, and how is it best achieved?

Fendrick: The second part of this question is much more challenging than the first. From their respective launches, the University of Michigan V-BID Center and COA have strived to engage with multiple stakeholders and to be politically non-partisan. A main goal of both organizations is to enhance access and affordability of evidence-based health care. These aims should not be and have not been very partisan.We work to create and implement policy solutions such that more individuals will be able to benefit from the best health care in the world. Unfortunately, patients increasingly confront barriers to access and affordability, and clinicians are faced with increasing workloads—driven partially the post pandemic catch up, expanding electronic medical record inboxes, and prior authorization—contributing to burnout and early retirement. These additional clinician burdens are often not be aligned with patients’ best interests and have motivated both the V-BID Center and COA to develop evidence-based non-partisan policy provisions promoting better access, outcomes, and equity.

EBO: You mentioned the IRA; are there other examples you can elaborate on related to the IRA or other current policy initiatives within the Biden administration that could benefit if policy leaders spent more time listening to physicians?

Fendrick: I think the inflation Reduction Act is a great example. Given that most people in clinical medicine as well as in the lay press are spending most of their time talking about the highly publicized drug price negotiations, it’s important to point out that the Inflation Reduction Act [IRA] supports several value-based insurance design elements. For instance, as of January 2023, Medicare Part D beneficiaries no longer had cost-sharing requirements for adult vaccinations recommended by the Advisory Committee on Immunization Practices, such as the shingles vaccine.⁹ Many more people know that Medicare beneficiaries who use insulin now pay no more than $35 a month out of pocket for their supply. Unfortunately, this policy has not been extended to commercial insurers, but there are efforts underway—bipartisan efforts—to extend that policy for insulin to individuals covered in the commercial market as well.

Maybe more importantly, as I look forward to January 2025, the IRA caps annual out-of-pocket spending for Medicare beneficiaries to $2000 a year and allows patients to spread those cost-sharing issues over 12 months, since many Americans don’t have $2000 on hand to pay on January 1. This policy will have particular importance to Medicare beneficiaries receiving cancer treatment. The Centers for Medicare & Medicaid Services published recently that in 2025, these IRA Part D drug-related provisions will lead to an estimated $7.4 billion reduction out-of-pocket spending for our most vulnerable Americans—those on Medicare—which can lead to an average savings of $400 per year.¹⁰ While it’s important to point out that the V-BID Center, and COA have achieved some important policy successes, both organizations continue to work further to enhance access and affordability.

There is important work to be done. Organizations such as the Community Oncology Alliance that put the needs of patients first, understand the requirement to align those patient needs with those of clinicians who can provide those services that lead to better individual and population health. This path is motivated by a need for enhanced equity, the creation of a more efficient US health care system, which is important given the increasing attention on how much we are spending as opposed to health outcomes (how well we are spending).

EBO: Is there anything else that you’d like to add?

Fendrick: There’s more than enough money in the US health care system. We just spend it on the wrong services on the wrong people in the wrong places in the wrong time. As more mission-driven organizations, such as the Community Oncology Alliance, align themselves with the goals of the V-BID Center—to spend more on the good stuff and less on the bad stuff—I can remain optimistic that US health care system could become more patient-focused, more equitable, and more efficient in its spending.

References

1. Medicare Prescription Drug, Improvement, and Modernization Act of 2003, HR 1, 108th Cong (2003). Accessed March 23, 2023. https://www.congress.gov/bill/108th-congress/house-bill/1
2. Caffrey M. Could this be the year for PBM reform? COA panel weighs in. The American Journal of Managed Care. March 24, 2023. Accessed November 17, 2023. https://bit.ly/3R3hKex
3. Center for Value-Based Insurance Design. Accessed November 21, 2023. https://vbidcenter.org/
4. Fendrick AM, Smith DG, Chernew ME, Shah SN. A benefit-based copay for prescription drugs: patient contribution based on total benefits, not drug acquisition cost. Am J Manag Care. 2001;7(9):861-867.
5. Fendrick AM, Chernew ME. Value-based insurance design: a “clinically sensitive” approach to preserve quality of care and contain costs. Am J Manag Care. 2006;12(1):18-20.
6. Howell BA, Kristal RB, Whitmire LR, Gentry M, Rabin TL, Rosenbaum J. A systematic review of advocacy curricula in graduate medical education. J Gen Intern Med. 2019;34(11):2592-2601. doi:10.1007/s11606-019-05184-3
7. Cubanski J. FAQs about the Inflation Reduction Act’s Medicare drug price negotiation program. KFF. August 8, 2023. Accessed November 17, 2023. https://bit.ly/3unpa3B
8. Fendrick AM, Smith DG, Chernew ME, Applying value-based insurance design to low-value health services. Health Aff (Millwood). 2010;29(11):2017-2021. doi:10.1377/hlthaff.2010.0878
9. Fix A, Hall J, Finkle M. Several changes to adult vaccine access enacted through IRA. Avalere. August 16, 2022. Accessed November 17, 2023. https://bit.ly/3SMJ7Ls
10. Sayed BA, Finegold K, Olsen TA, et al. Medicare Part D enrollee out-of-pocket spending: recent trends and projected impacts of the Inflation Reduction Act. July 7, 2023. Accessed November 17, 2023. https://bit.ly/3SIdoeh