Oncology: Value Based Care Ideas Starting to Emerge
Written by David Blaszczak, Senior Advisor at SCALE Healthcare
Bottom Line: The main driver in value-based care for oncology providers is still via regimen of drug treatment plans for the patient. However, as utilization of biosimilars continue to increase, other methods of patient care models are emerging to help drive savings besides drug costs. Initial patient screenings and patient call centers are being created with success to help take a holistic approach to the patient and their family to address social determinants of health, financial hardships, and treatment for conditions outside of cancer. We see these trends continuing to develop along with better coordination with primary care and other providers.
Over the past decade, value-based care models have been developed in most areas of treatment in healthcare around the U.S. However, oncology remains one of the specialties that have been slow to adopt models of value-based care. The Centers for Medicare and Medicaid Services (CMS) announced a demonstration and oncology value base care program in 2018 and Humana followed in 2019 with an announcement of their own program. Both programs have been very slow to show any significant success with any serious risk being taken by providers.
The largest potential share of savings generated in value-based oncology remains to be drug costs. Yet the biggest obstacle for value-based programs growing in the U.S. are provider groups willing to alter drug treatments for patients where a drug is lower in cost but considered equal in safety and efficacy. Physicians getting reimbursed for a percentage of the drug cost in Medicare Part B plays a role but so does providers controlling the patient care and not sharing information with primary care and other providers involved in care of the patient. The emergence of more biosimilars coming to market will test whether significant savings can be achieved via value-based care in oncology.
The largest potential share of savings generated in value-based oncology remains to be drug costs. Yet the biggest obstacle for value-based programs growing in the U.S. are provider groups willing to alter drug treatments for patients where a drug is lower in cost but considered equal in safety and efficacy.
On a recent webinar by hosted by Cardinal Health, Value Based Cancer Care, and Pontchatrain Cancer Center, a different approach was discussed that is gaining some traction among providers. In oncology, the patient sometimes faces the effects of financial toxicity because of the high costs of treatment. From worrying about out-of-pocket expenses to skipping or postponing treatment to soften the blow of costs, patients can face many direct and indirect costs of cancer. Drug companies sometimes will offer subsidized costs of care or free care, but patients must be eligible. Provider groups are now trying to alleviate some of these stressors by focusing on controlling costs at the point of care through a value-based care model that incorporates a patient screening program. This is a unique step in the direction of giving the patient more information and control of their care treatment regiment, and ultimately costs of care.
Pontchartrain Cancer Center, a cancer infusion center based in Louisiana, has successfully implemented a value-based care model at their centers to address social determinants of health and financial hardships their patients may be facing. By utilizing an initial patient screener, the center can implement a holistic approach to care, where the entire family unit is assisted in addition to the patient’s health needs. The patient screener also acts to identify high risk patients to help avoid potential adverse events. Before any treatments are initiated at the Pontchartrain Cancer Center, a financial discussion is held with the patient to help them be informed through their care process.
Provider groups are now trying to alleviate some of these stressors by focusing on controlling costs at the point of care through a value-based care model that incorporates a patient screening program. This is a unique step in the direction of giving the patient more information and control of their care treatment regiment, and ultimately costs of care.
While it can be difficult for providers to have financial conversations with their patients, especially surrounding oncology care, a way some practices are looking to reduce costs at point of care is by tapping into the biosimilars market and creating strong workflows for medication adherence.
Despite oncology providers slow to move towards models lowering drug costs, Pontchartrain Cancer Center has successfully reduced costs through use of biosimilars. While it can be difficult for providers to have financial conversations with their patients, especially surrounding oncology care, a way Pontchartrain Cancer Center and some other practices are looking to reduce costs at point of care, is by tapping into the biosimilars market and creating strong workflows for medication adherence.
Payers are slowly adopting biosimilars in coverage policies but sometimes the insurer implements authorization of use through prior authorization and step therapy. For example, the preferred biosimilar must be administered before receiving a nonpreferred biosimilar or the brand name drug. Payers will be careful in oncology where they will likely only allow most use of biosimilars into the treatment of patients who are new to treatment, and not a patient in mid treatment.
Setting up financial conversations about treatment with the patient through a screening process can help them become more involved in the process of their care. Pontchartrain Cancer center has used informing their patients as a strong suit in their payment plan designs and care workflows. Additionally, Pontchartrain Cancer Center has been able to create robust oral medication adherence workflows, since their patients are active and aware of the effects of their care.
The cancer center takes this one step further by offering a “Call Us 1st” program, where patients are encouraged to reach out with any issues they may be having related or unrelated to their cancer treatments in an effort to reduce ER visits and adverse events. Looking to the future, value-based care models in oncology will rely more on technology to track health risks for adverse events, episode analytics, and medical decision paths. Sharing this information with other providers, such as primary care and providers involved in the patient’s other medical conditions, will be key to gaining traction with successful value-based contracts with payers.
Looking to the future, value-based care models in oncology will rely more on technology to track health risks for adverse events, episode analytics, and medical decision paths. Sharing this information with other providers, such as primary care and providers involved in the patient’s other medical conditions, will be key to gaining traction with successful value-based contracts with payers.
Contact David Blaszczak for questions or comments about this article.