Cancer Payment Models Improve Care, but Making Them Work Takes Effort

Value-based payment models in cancer care have done much to improve outcomes and patient experience, and over time they can have positive effects on practice culture. But making the models work financially is painstaking, according to 3 practice leaders who discussed what it takes Tuesday during the Community Oncology Alliance Payer Exchange Summit, held in Tyson’s Corner, Virginia.

Michael Diaz, MD, president and managing physician, Florida Cancer Specialists & Research Institute, served as moderator for the discussion, “Cancer Care Team Perspectives on Oncology Reform Efforts and New Payment Models,” which featured:

• David Cosgrove, MD, medical director, Compass Oncology, which serves patients in the Portland, Oregon, and Vancouver, Washington, areas;
• Scott Kruger, MD, FACP, medical director, Virginia Oncology Associates, of Hampton Roads; other
• Aaron Lyss, MBA, senior director, payment and policy innovation, OneOncology, which serves 15 practices nationwide from its base in Nashville, Tennessee.

Diaz encouraged the panelists to share what has gone well with value-based care, and later, what has proved frustrating. Cosgrove said that Medicare’s Oncology Care Model (OCM), which ran from 2016 until June 2022, appeared to be a good fit for Compass initially. The practice was already delivering palliative care, and leaders believed the practice’s metrics would compare favorably to area competitors.

But early on, Compass was disappointed, Cosgrove said. It was hard to achieve savings until the practice had a “laser focus” on managing the cost savings and quality of life metrics. “With biosimilars, we saw cost savings at the end of the program,” he said.

Maintaining that focus was difficult during the pandemic, when practices had to deal with implementing telehealth and staffing shortages. Some models start with high ideals, Cosgrove said, but for those working them day to day, “there’s the perception, ‘I have to do my work and then this?’”

Kruger, whose practice serves some of the poorest areas in Virginia and North Carolina, had a more positive view of value-based care. “We’re a better practice because of it,” he said. Personnel shifts have directed more resources into patient services, including helping patients identify community resources for food or programs that can support drug costs.

The process of working with other agencies has allowed the practice to build partnerships and trust that go beyond delivering care. “It’s improved quality and changed our standing in the community,” he said.

OneOncology practices have worked with multiple payer models beyond the OCM, Lyss said, including oncology models developed by Aetna, Cigna, and Humana; Astera Oncology, which is among the 15 OneOncology practices, has worked on value-based models with Horizon BlueCross BlueShield of New Jersey. Although that experience is valuable, Lyss said the variation between different oncology models can create management challenges for a practice.

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

Kruger echoed a point heard throughout the sessions: Practices are unlikely to give different levels of care based on payment models. Instead, they will try to deliver the highest level of care possible to all, and work to make the financial side make sense. “The goal is not to make money on value-based care, but we don’t want to lose money—whatever we’re going to do, we’re going to do the same thing for every patient,” he said.

On the positive side, Cosgrove said the process of implementing value-based care “has made the whole team more engaged.” But turning around data has been a challenge—practices still wait roughly 18 months to get the full picture of how they will fare on shared savings. This can make it difficult to fully implement initiatives such as integrating additional social work services or putting added focus on certain diseases. “Keeping up the momentum is a struggle,” he said.

Diaz asked Lyss what benefits OneOncology saw from participating in value-based models. Lyss said there were still benefits, but the question was “increasingly tougher to answer.”

“It provides a vehicle for practices to make investments in care delivery that they want to make, that they might need to compete in their markets with the infrastructure of a hospital system or academic center,” Lyss said. This would include services such as care coordination, palliative care, psychology services, social workers, and financial counselors to help patients cover the cost of medications.

Embracing value-based care also allows for the investments in data analytics and claims infrastructure—all the “back end” side that provides measurement and fuel for practice transformation, which Lyss said results in the culture change that is critical for success when operating value- based payment models. “That doesn’t happen overnight,” he said.

Diaz asked the panelists to elaborate on current challenges with “carve-outs,” which are exceptions to overall value-based contracts among commercial payers that require practices to deviate from standard procedures. These requirements have increased as payers have become vertically integrated with pharmacy benefit managers (PBMs) and other health care delivery entities. As Lyss explained, carve-outs typically mean money for the payer and headaches for the practice.

“The payer will use their preferred vendor or vertical integrated joint venture for services that the practice wants to provide for the patients—especially services that are key to driving performance,” Lyss said. When there’s no transparency—especially in areas such as specialty pharmacy or imaging services—it makes it hard for practices to manage costs and quality.

“We’ve been successful in making the case why the OneOncology practices should be empowered in these models to manage patient care in these services,” he said.

Said Diaz, “We can see that in my practice, too. And the way I like to summarize it is that when patient care is fragmented, it makes it very difficult for the person who’s supposed to be quarterback in all of this…..Because these other parties don’t aren’t necessarily aligned.”

Kruger said he’s seen this in his area, where hospitals refuse to use less expensive biosimilars because they’d rather get the financial windfall from branded medications under the 340B program. “They want people to go to infusion centers,” Kruger said. “I don’t think they do as well as they think they do, and they charge 5 times as much for the drug.”

Diaz asked how practices that have worked with value-based payment models with one population—most likely Medicare patients—can start conversations to expand to other patient groups.

Kruger said this can be challenging if data are not available. An effort in his area to bring more alignment among psychological services has stalled for this reason. “As difficult as the lack of data is for us, the hospital also has a lack of data,” he said.

Encouraging “smaller bites of the apple” is a good place to start, Kruger said. “I can control where the patient goes, and how many times I see them,” he said. If needed, patients can come in more often. Kruger can decide when to start palliative care. When it comes to community services such as transportation or help with groceries, he said, “Sometimes you just have to ask, and you’ll be surprised what you’ll get.”

Lyss highlights the need for regular, ongoing contact. OneOncology’s practice, Tennessee Oncology, works closely with BlueCross BlueShield of Tennessee, and is in weekly contact on how to address issues such as steering or reduction in utilization.

In response to a question, Lyss said the experiences of the past decade in value-based care—including the years in the OCM—are what a management services organization such as OneOncology offers practices that have not tried value-based care but are considering the Enhancing Oncology Model (EOM).

Lyss acknowledged that parts of the journey were “painful” for the practices that were early adopters. “It took a long time to get the practice redesign that those practices have now,” he said. He warned that practices that are still holding out must understand that staying with the Merit-based Incentive Payment System (MIPS) will not be easy, because MIPS will change, too.

A “critical ingredient” is appreciating the need for culture change. “If a practice is willing to do that—if they’re bought in on the culture change front—there are a lot of other problems that will really help them solve….And once we have those, we can be able to help our clients to succeed in the EOM.”