Houston, TX—“Collaboration, coordination, data, and innovation are key to achieving value-based cancer care,” said Loreen M. Brown, MSW, Vice President of Reimbursement and Access Consulting, Xcenda, AmerisourceBergen Consulting Services.
Speaking at the Second Annual Conference of the Association for Value-Based Cancer Care, Ms Brown made the following points about the “evolving market” of oncology:
In the past, utilization management mainly centered around prior authorization to ensure appropriate use per the labeled indication. As oncology evolves to a more value-based process, coverage policies must be founded on value-based decisions that take into account meaningful outcomes, comparative effectiveness, and preferred therapies per treatment pathways or guidelines, Ms Brown noted.
The availability of multiple treatment options, oral oncolytics, generics, and eventually biosimilars in addition to standard intravenous (IV) chemotherapy drugs will further complicate the decision-making process.
“Value” Varies by Stakeholder
Stakeholders perceive “value” differently within the various components of cancer care (Figure):
In the current oncology system, balancing these priorities across stakeholder lines is challenging, Ms Brown said. Today’s system pays providers for volume of services and drugs, lacks the ability to collect and/or capture data for analysis, and offers no real basis for evaluating outcomes or value in a clinical, financial, or quality sense. “Without these things, it is hard to determine outcomes for value,” she said.
From the provider’s perspective, reimbursement is diminishing, patient out-of-pocket costs are increasing, shrinking margins are greatly impacting uncompensated services, reimbursement for managing self-administered therapies is lacking, and risk-/case-based reimbursements (ie, Medicare Shared Savings Program) are part of the picture.
In a 2011 survey of oncologists, Xcenda researchers asked how route of drug administration influences choice of therapy. Although 38% said it did not influence their selection, 17% preferred IV products because the copay is less for the patient, and 7% preferred IV products because they were economically beneficial to their practices. Oral agents were preferred by 13% as a result of patient convenience.
“These were all rational responses, but they were different due to competing priorities,” Ms Brown said. To illustrate this at the conference, she presented hypothetical treatment choices representing different reimbursement, copay, and other cost variables that may be preferred by some stakeholders for different reasons (Table). “Priorities are different, based on numbers like these,” she commented.
At the same time, administrative complexity is a growing problem especially for oncology practices. Payers require more management (prior authorizations, treatment pathways, and guidelines), and there is increased use of health information technology resources requiring electronic medical records and e-prescribing, decisionsupport tools, drug inventory cabinets, and data analytics tools.
“Practices that lack a skilled administrator are limited in their ability to run an efficient practice,” she observed. “This is increasing the number of mergers, hospital affiliations, and practices that are closing.”
AmerisourceBergen, in partnership with IM Solutions and US Bioservices, has developed a collaborative and tiered approach to oncology care delivery. The program coordinates practice networks in multiple states with national and regional/local payers, and integrates with US Bioservices contracts and capabilities for oral drugs, injectables, and medication therapy management.
The first tier, the program’s foundation, includes an innovative compensation program, provider/payer portal, reporting and analysis, and nucleus treatment pathways. The second tier, “value acceleration,” includes an advanced-care planning program, standard nurse triage program, and nucleus data exchange. The third tier, “program enhancements,” features a quality initiative program and a patient portal for educational purposes.
The model “pulls together much more data than you see on a claims form,” she said. “The payer and provider forum is useful for exchange of information. It is all implemented electronically, and it interacts with the drug ordering process and practice management software. The innovative compensation program takes the margin out of the drug and gives a management fee. There are variations on this theme, but, in general, this is what we are doing.”
Ms Brown concluded that “success” in achieving value in cancer care will require programs such as these that are developed through provider and payer (and even patient) partnerships. “Effective, evidence-based tools that work in concert with key stakeholders do exist,” she said, “and are continuing to evolve.”
