1. Eastman, Peggy

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The National Comprehensive Cancer Network (NCCN) hosted a virtual summit on promising approaches to lowering the costs of U.S. cancer care while preserving the highest standards of quality.

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According to National Institutes of Health data estimates, cancer care costs will rise to $173 billion by the end of 2020, prompting an urgent need for cost-containment solutions. Proposals to lower costs have varying implications for cancer care among health care providers, industry, payers, and patients, noted Alyssa Schatz, MSW, NCCN's Senior Director of Policy and Advocacy. Most proposals move away from fee-for-service toward value-based payment models.


The federal government is actively pursuing new payment models for cancer care, said Lara Strawbridge, MPH, Director of the Division of Ambulatory Payment Models at the Center for Medicare & Medicaid Innovation (CMMI). In a keynote address, Strawbridge said that, while Medicare's Oncology Care Model (OCM) has not resulted in hoped-for savings, "the results are early" and it takes a while for new payment processes to mature. She noted that "oncologists do believe that the OCM improves patient care."


Early data from CMMI show that the OCM model is leading to fewer inpatient admissions and intensive care unit stays in the last month of life. Strawbridge announced that the OCM has been extended; it will now end in the middle of 2022, not 2021. CMMI is now working on a successor to OCM, Oncology Care First (OCF), and on a proposed radiation oncology model. CMMI anticipates that the OCF would start in January 2021.


"Our leadership remains committed to continue to innovate in oncology care," said Strawbridge. "We continue to believe we can do better." She said a key reason why the OCM overall has not shown savings is that the group of patients with cancers considered low-risk under the OCM payment methodology had higher than expected costs-many of them non-related to cancer care. She said one key advantage of the OCM is that practices report that in the era of COVID-19 the OCM has helped them respond more nimbly to the public health emergency. "I for one have been proud to hear how the OCM is making practice flows better," said Strawbridge.


Defining the OCF Model

The proposed OCF payment model would be a new and distinct model from the current OCM, building on lessons learned, said Strawbridge. CMMI data note that, of the roughly 1.75 million Americans diagnosed with cancer every year, about half are age 65 or older and eligible for Medicare.


CMMI has stated that "the inefficiency and variation in oncology care in the United States is well-documented, with avoidable hospitalizations and emergency department visits occurring frequently, high service utilization at the end of life," and use of higher-cost drugs and biologicals when lower-cost options exist.


Strawbridge said that, as currently envisioned, the OCF model would include a prospective, monthly capitation payment per patient for an OCF participant's assigned population of Medicare beneficiaries with cancer. This would include payment for evaluation and management services and drug administration services.


Under the proposed model, a practice would be accountable for total Medicare costs, including drug costs, incurred during a 6-month episode of care with a chemotherapy drug. Practices would have the opportunity to achieve a performance-based payment; there would also be a novel therapy adjustment for newly approved, costlier drugs.


The proposed OCF model, which would be open to physician group practices and hospital outpatient departments, would stratify patients in three payment categories:


1. high-risk, those receiving chemotherapy stratified by cancer type;


2. low-risk, those receiving hormonal therapy stratified by breast, bladder, and prostate cancer; and


3. those receiving no hormonal therapy or chemotherapy for any cancer type, such as those under active surveillance and survivors.



Currently under consideration, said Strawbridge, is whether and how payment flexibilities adopted in the pandemic-such as expansion of telehealth-might be incorporated into the OCF. Questions to think about include the following:


* How is telehealth ideally provided in oncology?


* What flexibility changes in care are here to stay and what will go back to pre-COVID status?


* How long will care patterns and case mix be affected by the public health emergency?


* How can CMMI models take into account future public health emergencies?



Additional Tools of Value

Participants in a panel discussion at the NCCN summit stressed that better use of available tools such as evidence-based guidelines and value-based payment models such as the OCM can indeed help practices deliver cancer care cost-effectively.


"I absolutely see [the OCM] working," said Gena Cook, founder of Navigating Cancer and Chair of the NCCN Foundation Board of Directors. "I think we just need to stay the course. I see physicians as innovators, especially in community oncology.


"There's a lot more work to do, but the incentives are aligning to enable the transformations that improve patient experiences and care. As the market continues to move toward valued-based care, we've seen significant changes that have improved the patient experience and had an impact on reducing costs."


Better collaboration and coordination, care delivery partnerships, geriatric assessment, and the use of evidence-based guidelines can improve care management and close gaps in access to care, said Angela G. Mysliwiec, MD, Senior Medical Director at WellMed, a network of physicians, specialists, and professionals providing care for older adults in Texas and Florida. She advocated being proactive about symptom management, and said the OCM has had a ripple effect in improving cancer care.


"Evidence-based medicine should be the foundation of any oncology care model and results in high-quality care, as well as cost containment," she stated.


"Using guidelines-based care is very important for our patients," agreed Ruth O'Regan, MD, Chief of the Division of Hematology, Medical Oncology, and Palliative Care in the Department of Medicine at the University of Wisconsin, and Associate Director of Clinical Research at the University of Wisconsin Carbone Cancer Center. She also recommended the use of biosimilar drugs, noting that they "can offer cost savings with similar efficacy for patients," and better use of palliative care.


The increased use of biosimilar drugs, elimination of middlemen such as pharmacy benefit managers, along with rebates and discounts, and a move to value-based payment models could help to contain drug costs in oncology, said Ted Okon, MBA, Executive Director of the Community Oncology Alliance. He also put in a plea for elimination of waste and of aggressive end-of-life cancer care when what is needed is palliative care. "A lot of it is family members," he said. "Family members don't want to give up."


During a fireside chat, two speakers emphasized the need for better alignment in payer programs. "There are inconsistencies throughout the entire payer community.... We have a lot of room for improvement," said Thomas Daley, MBA, Director of Contracting for the University of Michigan Health System. "We would like to see greater alignment and consistency across various payer programs. Uniformity of quality and performance measures across value-based reimbursement plans would improve provider and institution performance. Clinicians could spend less time on administrative tasks if IT reporting capabilities for claims were more universal."


"Payers need to look at value compared to cost; they're kind of stuck in an old paradigm," said David Rubin, Director of Health Outcomes & Quantitative Analytics at Memorial Sloan Kettering Cancer Center. He said payers need to examine the specific societal benefits of keeping patients alive longer and getting them back to work sooner, so they can see the actual results of the money they are spending on care.


Rubin said payments for episode-based care and bundled care are a good strategy to keep costs down while preserving high quality. "I believe this is the way forward in oncology," he said. He noted that currently billing systems are designed for fee-for-service care and "there really needs to be a retooling of that."


Access and equity in cancer care are more important than ever in the era of COVID-19, said Michelle McMurry-Heath, MD, PhD, President and CEO of the Biotechnology Innovation Organization (BIO). "Science, the distillation of truth itself, is under threat," she said. "I really see science as the pathway to progress."


In a keynote address, she said BIO recently launched an equity agenda that stresses promoting health equity through access to drugs and diversity in clinical trials; investing in the current and next generation of minority scientists and entrepreneurs-through mentors and fellowships, for example; and expanding opportunities for women and minorities in biotechnology companies.


McMurry-Heath said it is important to rethink exclusion criteria for clinical trial participation, since many minority patients have co-morbidities. "We're doing work every day to try to increase minorities in clinical trials," she said.


She strongly advocated the continued use of telemedicine and remote tools that allow patients to participate in clinical trials no matter where they live. She noted that "time and again we get distracted by fighting for today," but "we can't take our eye off the ball for tomorrow." Equity in access to medicine today means access to the cures of tomorrow, she stressed.


Peggy Eastman is a contributing writer.