Four Ways Payers Can Advance Oncology Value-Based Pay

Twelve percent. That’s how much commercial payers stand to save by engaging in value-based contracts for cancer care, says Ron Barkley, president of the Cancer Center Business Development Group, which consults with oncology providers on value-based care arrangements.

Despite the upside, many payers are locked into legacy technology systems, “where they can’t deal with anything but claims data, and that prevents them from engaging with providers on value-based contracts for cancer care,” Barkley says.

In addition to technology hurdles, he says many payers are unwilling to be transparent about their total spend on cancer treatment for patients.

Still, he’s bullish on value-based care for cancer treatment. And he provides four changes payers can make to improve patient care while reducing costs.

1. Give a little. There’s a huge opportunity for providers to reduce total spend by using care management techniques to prevent patients’ unnecessary visits to the emergency room.

Through monthly payments to oncology providers, payers can partially subsidize the cost of hiring a care manager who can reach out to patients within 48 hours of their treatment. And the oncology provider can use insight gained from the calls to patients to determine if they need a prescription for anti-nausea medication or if a same-day appointment with an oncology nurse is appropriate.

2. Encourage performance transparency. “If there’s evidence-based medicine and documentation that these are the drugs that should be used for this condition, why would you not follow that?” says Barkley.

But changing providers’ behavior can be difficult. Key to making changes to cancer treatment is provider engagement, says Mah-Jabeen Soobader, PhD, chief analytics officer at Archway Health, which consults with providers, payers, and employers on value-based care programs.

She recommends tapping into physicians’ competitive nature and being transparent about the data associated with their performance when compared to other oncologists in their group or department. “Most times, they self-correct after looking at the data.”

3. Work with providers to help them manage patient expectations. Oncology providers need to be disciplined around terminal, end-of-life issues and educating patients and their family members about the true side effects of treatments, says Barkley.

That means providers shouldn’t be providing chemotherapy two hours before death or sending the patient to the intensive care unit for three days. Instead, oncology providers should be using palliative care and hospice, he adds.

4. Learn from other programs. Barkley describes CMS’ oncology care model, where providers and payers have entered into payment arrangements that include financial and performance accountability for episodes of care around chemotherapy administration to cancer patients, as “very well received,” with participation from approximately 190 organizations around the country.

“A positive of [the oncology care model] is just having a large-scale opportunity to start to understand the total cost that goes into cancer and the opportunity to reduce the spend with care management,” he says.

Still, the oncology care model performance-based payment methodology/prediction model is a “very aggressive, large program which is overly complex,” says Barkley.

The first indication of model deficiencies became apparent with the February 28 release of initial performance-based payment calculations for the first performance period, says Barkley. Reportedly, only 20% of oncology care model participants earned performance-based payment in the first payment period, he says.

Three of the challenges associated with the oncology care model’s predictive model, according to Barkley, include:

• Many patients weren’t attributed accurately to the providers delivering their oncology treatment.
• Statistical bias in the methodologies for treating prostate and bladder cancer.
• Lack of statistical adjustment for novel therapies, such as immunotherapies to treat leukemia and lymphoma, which were introduced after the 2012 to 2015 baseline price period.

CMS is aware of these challenges and making updates to the model to address these issues, says Barkley.