“Imagine that it’s 5 years from now, and we are in a situation where the cost of cancer care has flattened, and costs are even going down,” said Clifford Goodman, PhD, a Senior Vice President at the Lewin Group, turning to a panel of oncology and policy experts at his side. “What policies got us there?”
Answers came without hesitation:
Emerging after hours of intense discussion at the policy summit, convened online by the National Comprehensive Cancer Network (NCCN®), the answers conveyed a sense not only of the many issues affecting costs, but also a shared, unanimous sense of urgency as the search for workable solutions goes on.
“It’s an exciting time in oncology,” said Ms. Cook, who also chairs the NCCN Foundation® Board of Directors. “There’s a lot more work to do, but the incentives are aligning.”
The NCCN Oncology Policy Summit, Innovative Solutions to Drive Down Healthcare Costs: Implications for Access to High Quality Cancer Care, brought together speakers and panelists representing the Center for Medicare and Medicaid Innovation (CMMI), community oncologists, academic cancer centers, and patient advocates. In discussions moderated by Dr. Goodman, participants explored efforts at the federal level to reduce costs; the current state of value-based payment models; and efforts to initiate commercial value-based agreements. A final session addressed issues related to equity in cancer care.
At the Federal Level
A keynote topic at the summit was impending change in the way the Center for Medicare and Medicare Services (CMS) determines reimbursement for cancer care. Currently, CMS uses the Oncology Care Model, an episode-based, bundled payment plan instituted in 2016. A modified version, the Oncology First Model is expected to replace Oncology Care Model in 2022.
Keynote speaker Lara Strawbridge, MPH, Director of CMMI’s Division of Ambulatory Payment Models, said the Oncology First Model will establish a lump sum payment in advance, based on a participant’s assigned population of Medicare fee-for-service beneficiaries. This monthly population payment would replace the Oncology Care Model episode-based payment model. However, like the Oncology Care Model, the Oncology First Model would also offer the opportunity to receive a performance-based payment or owe a repayment to CMS (performance-based payment recoupment), depending on quality performance and costs.
Lara Strawbridge, MPH
As CMMI evaluates the Oncology Care Model and plans for Oncology First Model, she said, one area of interest has been the cost difference between high-risk and low-risk cancers. Low-risk cancers, such as breast and prostate cancers treated with hormonal therapies alone, are much less costly, with the result that overall savings with Oncology Care Model have been small. However, CMMI sees opportunities for cost savings in other areas, such as end-of-life care and drug acquisition strategies.
Legislators at the federal level have also become involved in the quest for more affordable care, with some supporting proposals to allow the importation of drugs from Canada and other countries. Another legislative proposal is to allow Medicare to negotiate the price of drugs.
The Oncology First Model will emphasize the quality of care, as does the Oncology Care Model. Both models are part of the general movement away from payments based on the number of procedures and toward value-based care, which pays based on various quality measures. Under the Oncology Care Model, quality measures have included the use of accepted clinical treatments based on guidelines; use of patient navigators; monitoring and managing pain intensity; and depression screening and management.
Has value-based care helped reduce costs? Dr. Goodman asked panelists.
“Yes, it is keeping patients out of the hospital,” said Dr. Mysliwiec, referring to the use of patient navigators.
“It is absolutely working,” agreed Ms. Cook, adding that it was too soon to know about the impact of some processes, such as automation.
“It is moving in the right direction,” said Mr. Okon. However, he noted, it would be improved by including standards related to medications, such as the following:
Expediting drug approval by the U.S. Food and Drug Administration, with priority given to biosimilars.
Encouraging the use of real-world evidence in evaluating new drugs.
Fixing the rebate system, under which drugmakers pay rebates to insurers and pharmacy benefit managers who cover their drugs; critics say the system encourages drugmakers to set high list prices and forces providers to use high-price drugs.
The panel also advocated including patients in cost discussions. “It is important to get patients more involved and to offer them choices,” said Ms. Cook. “This is a huge issue,” agreed Dr. O’Regan. “All information on costs should be shared with patients.”
Another area with the potential to lower costs is management of the patient journey—the steps from diagnosis to treatment to post-treatment care. “What key elements of that journey have the potential to lower costs?” asked Dr. Goodman.
“It is a complicated journey with many components,” observed Ms. Cook. “However, there are three parts that may be most important in determining costs: the choice of therapy, the choice of care management resources, and the choice of survivorship/endpoint care. It is important to think about value-based care at all these junctures,” she added. “There is a constant search for optimization across the journey.”
“Can the use of evidence-based guidelines affect cost?” asked Dr. Goodman. “Yes, guidelines are a foundational element,” said Ms. Cook. “They are clinically important,” agreed Dr. O’Regan, adding that cost is included in the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) with NCCN Evidence Blocks™, which support discussions with patients regarding the pros and cons of different approaches to treatment.
Commercial Value-Based Arrangements
As the focus of CMS on value-based care becomes established, commercial payers have begun to explore the feasibility of similar arrangements with employers and providers. In a conversation with two panel members, Dr. Goodman asked about the status of these efforts to date.
“We’re trying but not there yet,” said Thomas Daley, MBA, Director of Contracting for the University of Michigan Health System. “It’s a process in flux. We don’t know how to get there. We’re not all working together. We need greater alignment between the provider and the employer, and patients have to understand what they’re getting.”
“One of the challenges is that payment systems are based on fee for service,” said David Rubin, Director of Health Outcomes & Quantitative Analytics at Memorial Sloan Kettering Cancer Center, New York. “There needs to be a retooling of that. We see employers leading the charge.”
Overall, the most important step toward commercial value-based arrangements may be getting the provider and the employer together, Mr. Rubin said. “Everybody needs to sit down and discuss—pharma, employers, patients, clinicians.”
Mr. Daley agreed: “It’s going to take a lot of communication and a lot of trust,” he said. “But I think it can be done.”
Access and Equity
The NCCN Policy Summit took place against a background of evolving public health issues, such as the management of the COVID-19 pandemic and inequities in access to high-quality health care.
Terrell Johnson, MPA
Michelle McMurry-Heath, MD, PhD
In a final keynote session, Terrell Johnson, MPA, NCCN’s Manager for Policy and Advocacy, and Michelle McMurry-Heath, MD, PhD, Chief Executive Officer of the Biotechnology Innovation Organization (BIO), discussed the relationship between science and politics and the role of researchers in promoting equity in access to care.
In a pandemic, science is especially important, Dr. McMurry-Heath noted, but it can be undermined by politics—something that scientists must counter. “Our responsibility is to educate and advocate,” she said. “BIO works to make sure that science is not undermined by politics.”
Regarding equity, Dr. McMurry-Heath added that researchers are among those who can “make sure the future is equitable.”
One way they can do this is to improve minority representation in clinical trials, said Mr. Johnson, noting that NCCN emphasizes within its Guidelines for both professionals and patients that clinical trials provide the best care management for patients with cancer.
One strategy, Dr. McMurry-Heath said, is to make trials more patient-friendly, such as designing them to minimize disruptions in daily lives. Telemedicine, for example, could eliminate the requirement to travel in order to take part in a trial, making it accessible to patients no matter where they lived.
DISCLOSURE: Dr. O’Regan has received grant/research support from Novartis, Eisai, and Pfizer and has served as a consultant to Lilly, Pfizer, and Eisai. Dr. McMurry-Heath, Mr. Okon, Ms. Cook, Dr. Mysliwiec, Dr. Goodman, Ms. Strawbridge, Mr. Daley, Mr. Rubin, and Mr. Johnson reported no conflicts of interest.