Cancer payment models improve care, but making them work takes effort

Value-based payment models in cancer care play a big role in improving outcomes and patient experience, and over time, they can positively impact practice culture. But getting these models to work financially is a daunting task, said three practice leaders who discussed what needed to be done Tuesday at the Community Oncology Alliance Payer Exchange Summit in Tysons Corner, Va.

Florida Cancer Specialist and Institute President and Managing Physician Michael Diaz, MD, moderated a discussion “Cancer Care Team Perspectives on Oncology Reform Efforts and New Payment Models,” which featured:

  • David Cosgrove, MD, medical director of Compass Oncology, serving patients in the Portland, Oregon, and Vancouver, Washington areas;
  • Scott Kruger, MD, FACP, Medical Director, Virginia Oncology Society, Hampton Roads; and
  • Aaron Lyss, MBA, Senior Director of Payments and Policy Innovation, OneOncology, serves 15 clinics nationwide from its Nashville, Tennessee base.

Diaz encouraged panelists to share where values-based care went well and where it proved frustrating. The Medicare Oncology Care Model (OCM) from 2016 to June 2022 initially appeared to be a good fit for Compass, Cosgrove said. The practice is already delivering palliative care, and leaders believe the practice will outperform regional competitors on metrics.

But early on, Cosgrove said, Compass was disappointed. Savings are difficult to achieve until you practice “laser focus” to manage cost savings and quality of life metrics. “With biosimilars, we saw cost savings at the end of the program,” he said.

Maintaining this focus during a pandemic has been difficult, when practices have to deal with implementing telehealth and staffing shortages. Cosgrove said some models start with lofty ideals, but for those who do their day job, “there’s a perception of, ‘I have to do my job and then this?'”

Krueger, whose practice serves some of the poorest areas in Virginia and North Carolina, has a more positive view of values-based care. “We are a better practice because of it,” he said. Staffing changes have directed more resources to patient services, including community resources to help patients identify foods or programs that can be used to support drug costs.

The process of working with other agencies allows the practice to build partnerships and trust that go beyond providing care. “It improves quality and changes our standing in the community,” he said.

Lyss said the OneOncology practice has partnered with multiple payer models outside of OCM, including oncology models developed by Aetna, Cigna and Humana; Astera Oncology is one of 15 OneOncology practices that partner with New Jersey-based Horizon​​​ BlueCross BlueShield collaborate to develop a value-based model. While this experience is valuable, Lyss said differences between different oncology models can create management challenges for the practice.

When there are different quality or different clinical data reporting requirements between models, “even if 80 percent is the same, that 20 percent difference is very difficult to manage,” both at the point of care and at the administrative level, he said.

Krueger echoed a point heard throughout the session: Practices are unlikely to offer varying levels of care based on payment models. Instead, they will strive to provide the highest level of care for all and work to make financial sense. “Our goal is not to make money with value-based care, but we don’t want to lose money — no matter what we do, we’ll do the same for every patient,” he said.

On the positive side, Cosgrove said the process of implementing value-based care “made the whole team more engaged.” But turning the data around has been a challenge—practices still have to wait about 18 months to fully understand how they will enjoy shared savings. This can make it difficult to implement initiatives across the board, such as integrating additional social work services or focusing more on certain diseases. “Maintaining momentum is a struggle,” he said.

Diaz asked Lyss what benefits OneOncology sees from participating in a value-based model. There are still benefits, Lyss said, but the question is “increasingly difficult to answer.”

“It gives practices a tool to invest in the care they want to deliver, and they may need to compete in the market with the infrastructure of hospital systems or academic centers,” Lyss said. This will include services such as care coordination, palliative care, psychological services, social workers and financial counselors to help patients pay for their medications.

Adopting value-based care also allows for investment in data analytics and claims infrastructure—all the “back ends” that provide the metrics and fuel for practice transformation, which Lyss says leads to a cultural change that is critical to success when operating with value Important – based on payment model. “It’s not going to happen overnight,” he said.

Diaz asked panelists to elaborate on the current challenges facing “unbundling,” the exception to value-based monolithic contracts between commercial payers that require practice to deviate from standard procedures. These requirements have also increased as payers become vertically integrated with pharmacy benefit managers (PBMs) and other healthcare delivery entities. As Lyss explained, unbundling often means a headache for the payer’s money and practice.

“Payers will use their preferred provider or vertically integrated joint venture to deliver the services the practice wants to provide to patients — especially services that are critical to improving performance,” Lyss said. When there is no transparency – especially in areas such as specialty pharmacies or imaging services – this makes it difficult for practices to manage cost and quality.

“We have successfully demonstrated why OneOncology practices should be empowered in these models to manage patient care in these services,” he said.

“We can see this in my practice as well,” Diaz said. The way I want to sum it up is that when patient care is fragmented, it makes it very difficult for someone who is supposed to be a quarterback…because These other parties are not necessarily in agreement.”

Kruger said he’s seen it happen in his area, where hospitals refuse to use cheaper biosimilars because they’d rather get windfalls from branded drugs under the 340B plan. “They want people to go to an infusion center,” Kruger said. “I don’t think they’re doing as well as they think they’re doing, and they’re charging five times as much for the drug.”

Diaz asks how the practice of using a value-based payment model in one population (most likely Medicare patients) can start a conversation to expand to other patient populations.

That can be challenging if data isn’t available, Kruger said. For this reason, efforts to make psychological services more coherent in his area have stalled. “While the lack of data is difficult for us, hospitals also lack data,” he said.

Encouraging “apple nibble” is a good place to start, Kruger said. “I can control where patients go and how often I see them,” he said. Patients can come in more frequently if needed. Kruger can decide when to start palliative care. When it comes to community services like transportation or grocery help, he said, “Sometimes you just have to ask and you’ll be surprised what you get.”

Lyss emphasized the need for regular, ongoing contact. OneOncology’s clinic, Tennessee Oncology, works closely with BlueCross BlueShield in Tennessee and is in weekly contact on how to address issues such as diversion or reduced utilization.

In response to a question, Lyss said that the past decade’s experience with value-based care — including those in OCM — is a practice offered by managed service organizations (MSOs) such as OneOncology that have not attempted value-based care care, but is considering EOM.

Lyss admits that some parts of the journey were “painful” for early adopters. “It will take a long time to redesign the practices that these practices have now,” he said. He cautioned that those who still stick to it must understand that sticking to a performance-based incentive payment system (MIPS) will not be easy, as MIPS can also change.

A “key factor” is recognizing the need for cultural change. “If a practice is willing to do that — if they’re bought off in terms of cultural change — there’s a lot of other issues that can really help them out… Once we have those, we can help our clients succeed in EOM. “

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