“It’s Not Just About the Drugs”–A Much-Needed Rallying Cry for 2016

Dawn Holcombe, MBA, FACMPE, ACHE

April 2016, Vol 6, No 4 - From the Editor


“It’s not just about the drugs” is a common theme, and one that I have personally used often in discussions with payers and employers over the past 6 years. However, as value-based payment reform ramps up, it is equally impor­tant that oncology practices also embrace this phrase, for a variety of reasons, and in multiple venues.

New Proposal for Drug Reimbursement

The most pressing venue to use this phrase is with the Centers for Medicare & Medicaid Services (CMS). With its Medicare Access and CHIP Reauthorization Act (MACRA), which was passed into law in April 2015, and the March announcement of a proposal to test novel models of how Medicare Part B will pay for prescription drugs (see article on this topic next month), CMS has actually moved away from value-driven disease management and toward forcing drug cost onto physicians.

However, oncology care is not only about the drugs, and the proposal from CMS is a heavy-handed, drug-focused initiative that takes a significant step backward from how oncology management is evolving (away from the drugs) to advance toward true disease management. Benchmarking, population health data and management, and disease management are far more effective tools to support.

Medical community organizations (eg, the American Society of Clinical Oncology, Community Oncology Alliance, Association of Community Cancer Centers, American Society of Hematology, American Medical Association, and others) have responded quickly and negatively to CMS’s new proposal, denouncing it as an experiment that pushes the selection of drugs based on CMS’s definition of value rather than on value as defined by traditional medical review and a consensus of the most appropriate treatment as determined by specialists and treating physicians.

CMS has not worked with physicians or with other stakeholders to create this proposed drug payment model, to define “value” as used in this model, or to provide the necessary evidence to differentiate treatments and variable drug reimbursement for physicians.

Practices are being urged by many state oncology societies and national organizations to join the chorus of voices decrying this shortsighted and poorly focused CMS experiment that completely ignores the benefits of full-care oncology patient management in favor of pushing drugs by manipulating their costs to patients and physicians, regardless of what they paid to distributors or pharmaceutical companies for those drugs. Indeed, this new experiment flies in the opposite direction of the Oncology Care Model, which still has to be implemented and fully defined by CMS.

Another venue where “It’s not just about the drugs” is needed is with private insurers and employers. Increasingly, private insurers and vendors that sell oncology management services to employers and health plans are creating their own version of evidence-based clinical pathways.

In reality, these clinical pathways are focused more on the cost of alternative drugs than on the true clinical differentiation and individualization of treatments to patients based on clinical decision-making by their physicians.

In some states, legislation is now under way to address insurer clinical pathways and to call attention to the lack of transparency, viable evidence, and legality of what is essentially the corporate practice of medicine based on drug price rather than on medical evidence and oncology community consensus for the most appropriate clinical pathways.

Quality Care Is More Than Drugs

Practices across the country have been expanding their patient management services and have been reinventing themselves as oncology medical homes. They have been collaborating with colleagues and payers to create new value-driven models for the enhanced management of patients with cancer. Last year, CMS started supporting that oncology management growth by creating the Oncology Care Model project.

We have learned through past, recent, and ongoing projects that quality care is truly not about the drugs; increased savings and enhanced quality of care come from the effective management of patients, their expectations, their engagement, their symptoms, and their side effects rather than from the choice of drug.

We are starting to prove that pushing for treatment and reimbursement solely based on drug pricing is penny-wise and pound-foolish. Cheaper or older drugs may not manage symptoms and side effects as efficiently, which can result in higher costs for the management of patients’ complications and subsequent hospitalizations.

It is time for practices across the country to loudly and consistently point out to CMS and others who focus solely on drugs through ill-conceived programs or, at best, through well-intentioned but naïve programs, not to ignore the more complex issue of managing patients and their diseases. Drugs are a part of that, but we will collectively achieve our goals faster if we stop playing with drug pricing, step edits, and variable drug reimbursement, and focus on solid disease management initiatives.

It is also time to point out that “It’s not just about the drugs,” and we need to step forward with evidence-based, medical community–based initiatives that will work. Please reach out to your representative organizations, to your congressional officials, to CMS, and to private insurers at every opportunity to help them understand that effective oncology management will not happen if we continue to focus solely on the drugs.