In 2022, President Biden re-ignited the Cancer Moonshot with a call to cut the cancer death rate by half and “improve the experience of people and families living with and surviving cancer.” Both goals are ambitious and worthy. Cancer is prevalent and accounts for the second leading cause of death, right behind heart disease. It also imposes a tremendous and extreme economic burden on all parties. On a per-patient cost basis, it handily outpaces conditions like Alzheimer’s disease, diabetes, heart disease, and obesity. Further, patients with cancer in the United States shoulder a large amount of cancer care costs. Data shows that a half of all cancer patients incur some degree of debt after their diagnosis, and over 40% see their entire life’s savings wiped out in order to pay for treatment.
Confronted with the high and rising costs of cancer therapies, insurers often resort to utilization management strategies such as formulary exclusions, step therapy, or prior authorizations, but these tend to frustrate physicians and patients, and may actually lead to patient harm. But physicians and practice leaders know that there are many opportunities to both improve the patient experience, drive better outcomes, and reduce the total cost of care that are currently untapped. These include the provision of wraparound services such as patient navigation to respond to patient concerns and symptoms, facilitate care coordination, reduce acute care utilization, and improve goal-concordant care at the end of life. These interventions have been proven in study after study to lower cancer care costs, yet scaling these has proven difficult. Part of the problem is the fact that we currently live in a predominantly fee-for-service world.
In fee-for-service, health care providers are paid based on the individual care services provided, regardless of the effectiveness of that care. Such a model incentivizes high volumes, quick office visits, and reactive health care–wherein the physician is responding to a patient’s concerns but does not necessarily invest in forward-thinking strategies that would keep patients healthy and functional at home. In a fee-for-service world, it is difficult to stand up programs to address care coordination or electronic symptom reporting and capture because there isn’t always an easy billable code associated with such services.
Moving the needle: from fee-for-service to value based care
Yet, shifting away from fee-for-service and towards value-based payment models can be challenging. Value-based care ties the amount that health care providers earn for their services to the results that they can deliver, such as quality, equity, and cost of care. In payment models that involve downside risk, physician practices enter into risk-sharing agreements with a payer that allow them to keep any savings if costs fall short of an agreed-upon benchmark, but sustain penalties if costs overshoot the benchmark. This is a paradigm shift for many physicians and practices. Succeeding in these models requires more sophisticated technology to enable population-level insights on patient panels, new staffing models and scope of work, and a capital reserve or insurance to weather downside risk.
A tipping point: leveraging the new CMMI model to drive value-based oncology care
In 2015, the Centers for Medicare and Medicaid Innovation (CMMI) introduced the Oncology Care Model (OCM) – a cancer-focused value-based payment model. The OCM accepted approximately 200 oncology practices (representing nearly a quarter of all US medical oncologists) that entered into agreements with CMS with financial and performance accountability for 6-month episodes of care for patients undergoing chemotherapy. The OCM also offered prospective additional payments to practices that enabled them to invest in practice transformation activities, such as extended office hours, same-day urgent care visits, and nurse triage programs, and measured their cost performance against a benchmark to enable either further performance-based payments or penalties. While many practices reported that they successfully attained shared savings with CMS, CMS ultimately realized net losses on the experiment.
Given this experience, CMMI is now out with a new value-based payment model for cancer – the Enhancing Oncology Model (EOM), which launched on July 1. While the EOM resembles its predecessor in overall programmatic design, it is fundamentally a more difficult model for practices to tackle. For example, in the EOM, practices will face smaller monthly payments to fund practice transformation, mandatory downside risk, a smaller subset of cancer types included in the model, and more data collection and reporting requirements. In many ways, the EOM is the anticipated iteration for cancer value-based care, given that CMMI has previously outlined a vision for its models that included a plan to balance encouraging participation with sustainably generating savings. Unlike in the OCM, it is very likely that some practices may realize losses.
And yet, it is vital that physicians and practices participate in these models. Per their last strategic refresh, CMS has indicated that it aims to have all Medicare beneficiaries and most Medicaid beneficiaries enrolled in accountable care programs by 2030. This suggests that while models like the OCM and EOM are voluntary for now, future iterations may be mandatory. To the extent that practices can get their sea legs with value-based care now, they will be better poised for success down the road.
Getting ahead: practical take away for physicians and oncology providers
Physicians and practices that are open to delving into value-based care in order to stay competitive and deliver better care to their patients should pay attention to a couple key things. First, succeeding in these novel payment models involves a significant amount of data processing – access to relevant patient data from health information exchanges, patient-generated data, and claims data from CMS about a practice’s own and comparator practices’ data. CMS also requires that practices process and submit a fair bit of data to allow for more granular benchmarking of cost episodes. To the extent that practices can find the right data science and actuarial support to set up the pipelines, undertake processing and conduct analyses, these data requirements will be that much easier, smoother, and more actionable.
Second, value-based care payment models can involve new administrative burdens that are distinct from those imposed by the fee-for-service status quo. For example, practices may need to set up and monitor provider dashboards to understand and influence patterns of resource utilization and care delivery. They also may find it imperative to change their staffing models to allow for more resource intensity at the point of onboarding a patient to the practice, and utilize a mix of both clinical and non-clinical personnel to address the myriad issues that arise during the course of a patient’s cancer journey. Reducing administrative burdens and overcoming staffing shortages are two sides of the same coin – paying attention to one will pay dividends in the other.
Leveraging value-based care to achieve Cancer Moonshot
Value-based payment models had their start in the settings of primary care and discrete surgical procedures. Understanding how to operationalize and succeed in these in specialty outpatient care, and more specifically, within a disease entity as complex and heterogeneous as cancer is not straightforward. That being said, success in these new models can lead to more proactive, preventive care for patients, long-term financial security, and invaluable experience. EOM and Cancer Moonshot are the forcing functions to achieve VBC in oncology. In the spirit of working together to improve lives, this is a MUST for physicians to consider–before they get left behind.
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