Shifting Targets for Providers, Payers, and Patients with Cancer: Perspectives in Healthcare Reform

Gail Thompson

March 2017, Vol 7, No 3 - Cancer Center Business Summit


A panel discussion at the 2017 Cancer Center Business Summit revealed continuing gaps in the evolution of healthcare reform among providers, payers, and patients with cancer. Michael Kolodziej, MD, National Medical Director, Managed Care Strategy, Flatiron Health, New York, NY—an oncologist with experience on the provider and the payer sides—moderated the panel discussion, which offered perspectives from the trenches on healthcare reform.

Harlan Levine, MD, Chief Strategy Officer, City of Hope, and Chief Executive, City of Hope Medical Foundation, noted that California was recognized as an early leader in healthcare reform, with the emergence of large independent practice associations accepting risk from payers and then contracting with doctors for services. This pattern has been evolving since the establishment of HMOs approximately 20 years ago.

Dr Levine said that “the Affordable Care Act [ACA] didn’t necessarily reinvent healthcare in California, but did accelerate more integrated delivery systems and the risk systems associated with them.”

Accountable Care Organizations: Quality Metrics Fall Short of Reform

Steve L. D’Amato, BSPharm, BCOP, Executive Director, New England Cancer Specialists, Portland—the only remaining private oncology practice in Maine—noted that in Maine, the ACA’s impact was mainly expressed in the development of accountable care organizations (ACOs).

Mr D’Amato’s practice is part of a local ACO, but “the quality aspects, and reports where we really do well at the practice level, do not get reflected in the aggregated ACO quality reporting. So when we look at our QRUR [quality and resource use] reports, we look average, and we are scored on things that we really do not specialize in,” he said. Mr D’Amato is looking forward to his practice’s participation in the Oncology Care Model (OCM) reporting and scoring. There is a different set of oncology-specific OCM quality metrics, so oncologists can see how the specific practice looks from that set of quality metrics.

When Dr Kolodziej asked about the possible lack of “warm fuzzies” between oncologists and ACOs, Dr Levine commented that although there are several advantages to ACOs, primarily the integration of providers and care delivery, there can be disadvantages if the ACO provider network does not have the depth of services to provide appropriate cancer care, or if the incentives are misaligned.

“In an ACO, there is an unspoken incentive for keeping patients within the ACO system. A cancer patient’s primary concern is getting to the person with the right expertise and knowledge for their disease for the best care, whether or not it is part of the ACO system. Thus, we are seeing increasing friction between those 2 incentives,” Dr Levine said. “I think that if cancer is involved, the patients’ needs should come first, and we will need to find that balance. If you can find that balance, then warm and fuzzy feelings from physicians may return for ACOs.”

Dr Levine echoed Mr D’Amato’s concern about quality metrics failing to meet the needs of evolving healthcare reform. The metrics that ACOs use do not measure what would reflect quality in the oncology setting. There are many measures that do not relate to the actual practice of oncology.

The system needs to reflect what quality is from the point of view of the patient and the oncologist—the outcomes, the speed of care, and the impact of comorbidities. When you start measuring these aspects of quality care, Dr Levine believes that we can create a system that puts the oncologist on equal footing with the needs of the ACOs.

“I don’t think it is a matter of if we are treated well by the ACOs. I think that the system isn’t really mature enough to measure the quality of oncology care at the current time,” Dr Levine said. “We don’t need a one-size-fits-all ACO solution. We should have an understanding that there are certain conditions—dialysis being one, oncology could be another—that really need to be treated different by the system. And if you do that, then the positives of ACOs—the care coordination between doctors, the communications, and the aligned incentives—would then be able to emerge,” he suggests.

Payment Models

The ACA was recognized as having helped patients in some arenas. Alan J. Balch, PhD, Chief Executive Officer, Patient Advocate Foundation (PAF), noted that before the rollout of the ACA, upwards of 30% to 40% of PAF’s patients were uninsured; now that number has dropped to 10% of the member population. In that sense, the ACA has worked to provide access to health insurance. However, he says, the ACA was not designed to address the total costs of care.

The foundation is now focusing on utilization management review, process assistance, and financial assistance. He thinks that the Medicare Access and CHIP Reauthorization Act (MACRA) value-based payment program is our best shot to address the costs of healthcare problems. There is still a gap between the ACA and MACRA goals, and Dr Balch expressed hope that we could get the payment model figured out, so that we could marry it with the coverage model.

Access and Cost of Care

The costs of care were also addressed from the payer perspective by Dr Kolodziej, who said that “the ACA created a lot of new customers, but they were ‘bad’ customers. The amounts for premiums the insurers were receiving were not adequate to cover the risks that were generated in the risk pool. The challenge is that we really haven’t addressed the costs.”

On a national level, all panel participants expressed concern about the need to discuss access to care and access to innovation with respect to the costs. Although a prime focus of the ACA, the panelists noted that access to care was not really a big problem in and of itself.

Mr D’Amato stated that their practice “takes in all patients, including the uninsured, and we are very proud of that. We tend to want to keep those patients in our system because we are proud of our quality and value model. We tend not to drive those patients to hospital systems at a higher cost unless it is absolutely necessary.”

Dr Balch stated that PAF encounters access issues for patients, but from a very wide perspective. They track approximately 160 different patient concerns, and access issues can include provider network design, benefit design, and formulary design.

“If there is one common theme we see for access issues, it is transportation—that comprises about 10% to 15% of the total patient issues we deal with. With our diversity of issues, anything that hits the 10% threshold becomes pretty significant,” Dr Balch said. Patients have many fundamental problems, and for this patient population, Dr Balch feared that it does not matter what healthcare reform is enacted, because many patients that PAF helps will always need a safety net.

“You are not going to be able to bring hospital, physician, or pharmaceutical costs down enough to be able to serve the types of patients that we serve,” he said. “What is going to be the safety net?” Most of these market-based philosophy models are not designed to provide equal care to all people for the same benefit. If we are going to go in that direction, we have to consider the safety net, because there will be more people who fall between the cracks, Dr Balch noted.

The goal of the ACA is not to solve the issues of good care. It was trying to solve underinsured and uninsured patients. We now need to look closely at those strategies to find better solutions.

Dr Levine put forth a challenge, stating, “We know there are things we do in academic centers that are wasteful. We have built large infrastructures, and there are opportunities to look at the nuances for opportunities, perhaps by better defining effective clinical research or taking a consultant point of view.” He added, “Payers…need to understand that not all healthcare can be driven to the lowest cost solution as a single price model for healthcare. I see the solution as a partnership between the payers and the providers, which is emerging but still at very early stages, where people do come together and have a discussion about what is and what isn’t of value. Until you start talking about value, in a common language, there is no hope for a common solution.”

Challenges in Transforming Healthcare

The discussion then addressed the role of transformation in healthcare reform; the panelists agreed that the Center for Medicare & Medicaid Innovation has been the most catalytic for transformation in recent years.

Dr Balch expressed concern that the voice of the patient has been left out of the transformation equation so far, noting that “If we are going to go down this road and truly transform healthcare, the more we can provide the kind of information that patients need to truly be consumers and stewards of their healthcare dollars, the more successful we will be.” He brought up the need for new, lower-cost solutions to help with the patient communications and navigation.

“Most of the time patients spend is not in the hospital, is not spent with the physician; it is outside of the 4 walls of the clinic. So, if you don’t use mobile technology to leverage that patient, and get them engaged in their care on a 24/7 basis, and sharing that information back with the care center, you are missing a huge opportunity to really have your patient be a part of the care plan, be a steward of their own health,” Dr Balch said.

“Navigation is a key part of it, and you can use a tool that creates that same dynamic interface (it doesn’t have to be an actual person) that essentially serves the same role as navigation, but that doesn’t carry the high costs. It doesn’t work for everyone, but for the majority of people, that simple technology connection really works. Well, it isn’t really simple, but it looks simple to the user. The back end of it is highly complicated, but we do have the ability to do that with technology today. We are not really taking advantage of it yet, but we can,” Dr Balch suggested.

Technology was also posed as a challenge for providers in the healthcare reform arena. Mr D’Amato appreciates that the Centers for Medicare & Medicaid Services has provided 3 years of claims data as part of the OCM project, but most practices, he says, do not have the in-house capabilities to run the analytics needed for the quality improvement aspects of the OCM.

“The $160 OCM Monthly Enhanced Oncology Services payment doesn’t go very far when you look at what you have to do in house, just for data analytics to find the touchpoints where you can make a difference. I have an in-house data analyst who is spending his time getting us ready for the 5 data points we need to report by February 28. A lot of this is just manual work, because a lot of the fields required for the measures are not available electronically. All this has really highlighted the need for better data capture, and better analytics moving forward,” Mr D’Amato said.

Even outside of the OCM, healthcare transformation is costly. City of Hope is not eligible to participate in the OCM, but is still transforming care. A few years ago, it hired a number of care navigators. Dr Levine said that City of Hope’s transformation is focused on interdisciplinary care, patient engagement and psychosocial support with technology support, and partnering across the community. The cost of care is going to remain a challenge for everyone. When OCM and value-based care moves toward 2-sided risk, academic medical center care will be at a disadvantage because of their infrastructures.

“We are making great strides toward systems that address costs, but we are only at the start. There is a great deal of work to still do. If you look at payers and big pharma stock prices since the ACA, they are doing very well. Hospitals, physicians, care providers, and patients have not fared so well. If the new administration can shift some of that value from payers and pharmaceuticals to hospitals, physicians, and patients, I think we’ll be on the right road,” Dr Levine said.

The final assessment of the panel was that healthcare reform is more active than ever, but we still face significant challenges and differences of perspective. Open communication and moving toward a common language will be major drivers of success.