Editor’s Note: In late June 2022, the Centers for Medicare & Medicaid Services’ (CMS) Innovation Center (CMMI) launched the Enhancing Oncology Model (EOM), an alternative payment model seeking to incentivize providers in oncology practices to offer “whole-person care” while also providing value. In a new white paper, summarized below, Manatt Health provides an overview of the landscape related to value-based cancer care and offers strategies oncology providers can develop now to prepare for a changing reimbursement environment. The paper also describes examples of how CMS, commercial payers and employers are seeking to advance alternative payment models for cancer care. Click here to download a free copy of the full white paper.
The past 20 years have brought tremendous progress in cancer outcomes with improved screening and new treatments, such as immunotherapy, but with these innovations and our country’s aging population, escalating care costs and quality variation continue to confound the system. As public and private payers seek to achieve high-quality, equitable and affordable cancer treatment in the future, efforts to pursue value-based approaches have occurred in a halting fashion, challenging providers and payers to navigate this evolution. However, there are strategies that health systems and oncology service lines can pursue today that will be beneficial in the current, primarily fee-for-service environment while serving as preparation for a value-based future.
The American Society of Clinical Oncology defines value for cancer care as a combination of clinical benefit, side effects and improvement in patient symptoms or quality of life in the context of cost.1 Many factors contribute to the drive toward value-based cancer care, but perhaps the most significant relate to rising cost and evidence that a sizable portion of cancer patients fail to receive care in accordance with treatment guidelines.2 U.S. cancer-related health care costs are expected to grow by 34% between 2015 and 2030, to $246 billion.3 These escalating costs pose a significant burden to the overall health care system, employers and individuals.
Drivers of Value-Focused Cancer Care
There are five key drivers of value-focused cancer care:
- The continued and growing cost burden on patients
- New players and new models that threaten historic health system margins
- The high cost of new therapies and treatments
- The increase in incidence, driven by an aging population and COVID-19-related screening delays
- Payers’ and employers’ focus on ensuring high-quality, patient-centered care
In response to these drivers, health care payers and providers have been experimenting with episode-based bundles, global payments and shared-savings models to try to improve cost-effectiveness in cancer care. However, in addition to being challenging to implement, these models’ effectiveness in advancing value has not been clearly demonstrated, so adoption has been slow.
In late June 2022, CMMI launched the Enhancing Oncology Model (EOM),4 an alternative payment model seeking to incentivize providers in oncology practices to provide “whole-person care,” including screenings for health-related social needs, services to help patients navigate their cancer care needs, care planning, solicitation of patient-reported outcomes data and other activities that promote health equity. EOM is a voluntary program slated to launch in 2023. Participating practices will receive a monthly payment to provide “enhanced” services for assigned beneficiaries and will have an opportunity to receive incentives or shared savings for retrospective quality and cost performance.
Strategies for Health System-Based Cancer Programs to Navigate the Value Environment
A shift toward value will require a significant reorganization of care delivery across the continuum from risk assessment, prevention and screening through treatment, surveillance and survivorship to palliative care and end-of-life care.5, 6 Providers can prepare for this by developing strategies that are beneficial in the current environment while building capacity for the future and piloting initiatives with manageable risk.
There are four strategic levers to support success in value-based care:
1. Restructuring Care Teams for Value
- Align multispecialty clinical teams. Physician engagement and economic alignment across cancer specialty physicians and with primary care physicians are the top priorities for coordinated and efficient value-based cancer care. Hospital strategies to engage providers across specialties in planning and implementation and sharing data on quality and cost are critical.7
- Redesign care teams. Cancer care teams will have to be reconstituted to ensure care is delivered in the most cost-effective settings by the most cost-effective providers. Establishing a clinical practice model that has staff working at the top of their license will require increased utilization of advanced practice providers (APPs) and expanded roles for nurses.
2. Better Integrating and Disseminating Complex Internal and External Data
- Integrate internal data across the organization and providers. Health systems that mine and disseminate robust internal data on clinical costs, care quality and outcomes (including patient-reported outcomes) by specific diagnosis can support their cancer teams in addressing issues and driving change toward value.
- Participate in benchmarking networks. Participation in networks or programs such as American Society of Clinical Oncology (ASCO) CancerLinQ, Flatiron Health and COTA offers large databases and advanced data analytics to providers seeking real-world evidence to compare patient outcomes.
- Adopt and refine cancer clinical pathways. For hospitals with multiple care delivery locations and providers, especially with a mix of generalists, clinical pathways are a valuable tool for reducing variation in care. While treatment cost has not been included in many of the current products, there is value in their inclusion in future clinical pathway tools.8
3. Accelerating the Delivery of Cancer Care Outside Hospital and Clinical Settings
- Build and refine ambulatory capabilities in more convenient access locations. Developing ambulatory sites in communities beyond the hospital enables providers to offer patients more convenient and often lower-cost care options as compared to hospital-based services, as well as to better reach historically under-resourced populations.
- Continue to develop telehealth solutions. This trend, accelerated in response to COVID-19, has been shown to be a useful tool to ease the burden on patients and improve access. For cancer, telehealth has been effective for symptom management and for services that typically experience a high no-show rate (e.g., palliative care, psychosocial care and monitoring patients on clinical trials).
- Advance hospital- and clinic-at-home programs. Care “anywhere but the hospital” should be expanded with innovative programs to manage care or symptoms at home. This requires building a dedicated oncology home care team with APPs, nurses, pharmacists and other support personnel who closely coordinate care with oncologists and the use of technology (i.e., telemedicine, remote monitoring, wearables). Some examples include:
- Short-duration home care. Hospital cancer programs should work with an internal home care team or establish a partnership to set up a short-duration home-based program to manage the resolution of symptoms at home rather than in the hospital.
- Home chemotherapy. While the financial advantages for hospitals are very limited in the near term, especially with 340B programs, and setting up these programs is a new and very different business for cancer programs, there is increasing pressure from payers and from physician-hospital organizations, clinically integrated networks (CINs) and other similar vehicles that assume risk to offer this service for patients. Hospital cancer programs and physician groups—especially those with full-risk contracts—should begin to explore setting up these programs and consider pilots for patients for whom coming to the hospital infusion center is a challenge.
- Outpatient bone marrow transplants (BMTs). BMTs typically have associated hospital stays of several weeks. Duke was an early adopter of outpatient and home-based BMT programs in the United States, and the program has significantly reduced the cost of care since its launch in 2014.9
4. Transforming High-Impact Clinical Practices
- Establish accessible screening and diagnosis services. Accessible screening services, particularly for some of the most common cancers—such as cervical, colorectal, breast and lung—allow providers to find these cancers at an early stage, when treatment is most effective. As the U.S. health care system continues to wrestle with COVID-19 impacts, it is important to re-engage patients in regular screenings built into the standard care model.
- Promote cost-effective and appropriate use of cancer drugs and molecular testing. The rapid development of new high-cost cancer drugs10 and molecular tests is placing a significant financial burden on patients and providers. Providers must be proactive in assessing the cost-effectiveness of drugs that are included in their formularies and managing drug-prescribing practices. Many payers are also addressing this issue through a pre-authorization process. In parallel, hospital cancer programs should develop plans and processes to ensure appropriate ordering practices for molecular testing, with strategies such as test panels by disease site, the use of molecular tumor boards to advise physicians and coordination with pathology to ensure cost-effective sources for this testing.11
- Advance early palliative care and shared decision-making. Palliative care has been shown to be associated with deaths not occurring in an acute care setting and reduced hospital admissions and ED visits.12 Palliative care should be integrated into clinical pathways and the outpatient setting. It is important to begin early in a patient’s diagnosis, especially for stage 4 patients, to ensure that there is a focus on quality of life and symptom management and that patients are engaged in decision-making about the course of their treatment.
- Reduce use of intensive care units (ICUs) for cancer patients. ASCO Quality Oncology Practice Initiative (QOPI), Vizient and others have quality measures that track ICU days in the last 30 days of life. Hospitals need to be more proactive in analyzing this data to identify risk factors for the development of upstream interventions (e.g., having no caregiver at home), address other social drivers of health (SDOH) and coordinate with physicians to influence practice patterns.13
- Assess and address issues related to SDOH on cancer patients. SDOH are a significant factor in cancer care, particularly related to late diagnosis, compliance with treatment, long lengths of stay, and readmissions or ED visits. Cancer programs need to expand efforts to identify patients at higher risk and develop individualized plans to better support them through treatment and survivorship with issues such as food or housing insecurity.14, 15
The challenge in the short term for providers is to prepare for value within the current reimbursement environment. However, with CMS pressing ahead with the new EOM, it is clear that expectations for value will continue to grow. Many of the strategies outlined can be beneficial today while building capacity for success in a future value environment—one that enables funding for prevention, equity and patient-centered care across the continuum.
1 Schnipper, L. E., Davidson, N. E., Wollins, D. S., Blayney, D. W., Dicker, A. P., Ganz, P. A., Hoverman, J.R., Langdon, R., Lyman, G. H., Meropol, T.M., Newcomer, L., Peppercorn, J., Polite B., Raghavan, D., Rossi, G., Saltz, L., Schrag, D., Smith, T. J., Yu, P. P., Hudis, C. A., Vose, J. M., & Schilsky, R. L. (2016). Updating the American Society of Clinical Oncology Value Framework: Revisions and Reflections in Response to Comments Received. Journal of Clinical Oncology, 34(24), 2925 – 2934. http://doi.org/10.1200/JCO.2016.68.2518
2 Richards, J. M., Burgon, T. B., Tamondong-Lachica D., Bitran, J. D., Liangco, W. L., Paculdo, D. R., & Peabody, J. W (2019). Reducing Unwarranted Oncology Care Variation Across a Clinically Integrated Network: A Collaborative Physician Engagement Strategy. Journal of Oncology Practice, 15(12): e1076 – e1084. https://doi.org/10.1200/JOP.18.00754
3 American Cancer Society Cancer Action Network (2020, October 22). The Costs of Cancer: 2020 Edition. American Cancer Society Action Network. https://www.fightcancer.org/sites/default/files/National%20Documents/Costs-of-Cancer-2020-10222020.pdf
4 Centers for Medicare & Medicaid Services (2022, August 9). Enhancing Oncology Model. U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. https://www.cms.gov/newsroom/fact-sheets/enhancing-oncology-model
5 Kline, R. M. (2021). Bundled Payment Models in Oncology: Learning to Think in New Ways. JCO Oncology Practice, 17(4), 169 – 172. http://doi.org/10.1200/OP.20.00735
6 Jeremias, S. (2021, June 16). Oncology Roundup: Conference Presentations Illustrate Impact of New Cancer Therapies. American Journal of Managed Care. https://www.ajmc.com/view/oncology-roundup-conference-presentations-illustrate-impact-of-new-cancer-therapies
7 Richards, J. M., Burgon, T. B., Tamondong-Lachica D., Bitran, J. D., Liangco, W. L., Paculdo, D. R., & Peabody, J. W (2019). Reducing Unwarranted Oncology Care Variation Across a Clinically Integrated Network: A Collaborative Physician Engagement Strategy. Journal of Oncology Practice, 15(12): e1076 – e1084. https://doi.org/10.1200/JOP.18.00754
8 Bosserman, L. D., Cianfrocca, M., Yuh, B., Yeon, C., Chen, H., Sentovich, S., Polverini, A., Zachariah, F., Deaville, D., Lee, A. B., Sedrak, M. S., King, E., Gray, S., Morse, D., Glaser, C., Bhatt, G., Adeimy, C., Tan, T., Chao, J., …Johnson, D. (2021). Integrating Academic and Community Cancer Care and Research through Multidisciplinary Oncology Pathways for Value-Based Care: A Review and the City of Hope Experience. Journal of Clinical Medicine, 10(2): 188. https://doi.org/10.3390/jcm10020188
9 Fisher, M. (2014). Duke Performs First At-home Bone Marrow Transplant. Duke Cancer Institute.
10 Howard, D. H., Bach, P. B., Berndt, E. R., & Conti, R. M. (2015). Pricing in the Market for Anticancer Drugs. Journal of Economic Perspectives, 29(1): 139 – 162. https://doi.org/10.1257/jep.29.1.139
11 Hsiao, S. J., Sireci, A. N., Pendrick, D., Freeman, C., Fernandes, H., Schwartz, G. K., Henick, B. S., Mansukhani, M. M., Roth, K. A., Carvajal, R. D., & Oberg, J. A. (2020). Clinical Utilization, Utility, and Reimbursement for Expanded Genomic Panel Testing in Adult Oncology. JCO Precision Oncology, 4: 1038 – 1048. https://doi.org/10.1200/PO.20.00048
12 Sullivan D. R., Chan, B., Lapidus, J. A., Ganzini, L., Hansen, L., Carney, P. A., Fromme, E. K., Marino, M., Golden, S. E., Vranas, K. C., & Slatore, C. G.(2019). Association of Early Palliative Care Use With Survival and Place of Death Among Patients With Advanced Lung Cancer Receiving Care in the Veterans Health Administration. JAMA Oncology, 5(12): 1702 – 1709. https://doi.org/10.1001/jamaoncol.2019.3105
13 You, H., Dizon, D. S., Wong, N., Martin, E. W., & Fenton, M. A. (2020). Retrospective Chart Review to Characterize Admission to the ICU in the Last 30 Days of Life and Use of Systemic Anticancer Therapy in the Last Two Weeks of Life at the Lifespan Cancer Institute. Journal of Clinical Oncology, 38(15): supplement. https://ascopubs.org/doi/abs/10.1200/JCO.2020.38.15_suppl.e19202
14 Clark, C. R., Baril, N., Kunicki, M., Johnson, N., Soukup, J., Ferguson, K., Lipsitz, S., & Bigby, J. (2009). Addressing Social Determinants of Health to Improve Access to Early Breast Cancer Detection: Results of the Boston REACH 2010 Breast and Cervical Cancer Coalition Women’s Health Demonstration Project. Journal of Women’s Health, 18(5). http://doi.org/10.1089/jwh.2008.0972
15 Gottlieb, L., Tobey, R., Cantor, J., Hessler, D., & Adler, N. E. (2016). Integrating Social And Medical Data To Improve Population Health: Opportunities And Barriers. Health Affairs, 35(11). https://doi.org/10.1377/hlthaff.2016.0723