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Achieving Success in Value-Based Payment Models Through Pathway Adherence

Read original article HERE.

Stephen M Schleicher, MD, MBA, medical oncologist at Tennessee Oncology and medical director of value-based care at OneOncology, and colleagues recently published a viewpoint article in JAMA Oncology on how the Oncology Care Model (OCM) could better foster the use of appropriate cancer therapies.

Journal of Clinical Pathways spoke with Dr Schleicher on the ideas described in the article and how clinical pathways might be the answer.

How may the “skyrocketing prices” of novel therapies ultimately keep OCM from being a complete success?

Dr Schleicher: When I think about OCM, I think of it as a care delivery model. CMMI made that part of their goal by offering MEOS payments to practices that have volunteered to enroll in the Oncology Care Model. That is used for additional FTEs, for care coordinators, nurse navigators, etc, as well as analytics to help us really understand when a hospitalization might be prevented or when an emergency room visit could be avoided.

I think that the high prices of new therapies that have come out since OCM began almost distracts from what the model is supposed to do. You can do everything right with the appropriate care coordination and still not succeed in OCM because of the high prices of these new drugs.

If anything, it is really diluting some of the excellent efforts taken to help keep care at home when possible and in the clinic instead of in the emergency room, hospitals, etc.

How has CMMI attempted to account for the rising cost of novel cancer treatment in OCM performance‑based payment methodology?

Dr Schleicher: First of all, I applaud CMMI for recognizing prospectively that this was going to be a problem, even though our data shows that the current performance-based payment methodology is still an imperfect mechanism to account for the rising cost of treatment.

CMMI uses two different adjustments on the expected cost to help account for this. The first is the most important one, the trend factor, which accounts for medical inflation over time due to new drugs, expanding treatment indications, and increasing drug prices. The second factor is novel therapy adjustment, which adjusts for how much a given practice uses novel therapies compared with similar practices.

A “novel therapy” by CMMI’s definition in OCM is a drug or a new indication for an established drug for the 2 years following FDA approval. There is some debate that maybe NCCN recommendations, which often come before FDA approval, might be a better start date for listing a drug as a “novel therapy.”

The successor to OCM that is being proposed, the Oncology Care First Model, has an update to the novel therapy adjustment and trend factor. It aims to apply these to the disease at the actual episode level instead of the treating population level. This will hopefully better account for rising drug prices in these new indications moving forward.

Even as some practices have succeeded in cutting down ED visits, hospitalizations, and post-acute care stays, your study found that the costs of care remained higher than target costs because clinicians used NCCN-recommended novel therapies. How is holding providers accountable for inappropriate utilization of drugs or pathway nonadherence rather than costs an appropriate course of action?

Dr Schleicher: The most important thing that all oncologists, providers, and CMMI would say is we want patients in front of us to get the right drug at the right time, independent of cost. The right drug for them must have the best chance at improving outcomes. That is the goal.

By holding providers accountable for pathway adherence or appropriate utilization vs total cost of drugs, we in turn do a better job at tying accountability with control. For instance, if a clinician uses a low-value drug when it is not indicated or a better alternative exists, then the clinician should be held accountable.

There are a few examples in which a pathway would really help dictate that the clinician uses the right therapy for the right patient at the right time, yet not penalize the clinician for using the expensive immunotherapy when it is appropriate.

Pathways are aligned with CMMI’s goal – that is, disincentivizing low-value drug utilization without discouraging use of high-value drugs, irrespective of cost.

Is it as simple as designing pathways so that they are supporting the right regimens for the right patients at the right time at the highest quality? How should pathways be designed and implemented in order to help practices achieve success in value‑based payment models?

Dr Schleicher: There are three aspects of pathways that are important for achieving success in value‑based care. First, providers need assurances that the pathways are supporting optimal care for the patient at the right time. This entails a balance of quality and cost. Quality is always the trump card; cost plays a role when there is a comparable alternative.

Secondly, the pathways need to be implemented at the point of care rather than in retrospect. In other words, they need to be integrated into the EHR so that when a provider picks a regimen, the pathway guides that process instead of requiring a look at a separate window outside of the EHR.

Lastly, pathways need to be updated as soon as possible after practice change in data is presented, either at big conferences like ASCO or ESMO, or in the literature, so that we are confident that we are not in any way missing an opportunity for cutting-edge care.

It is important for pathway committees to meet regularly and have the opportunity for ad-hoc meetings as new data is presented. At OneOncology, we have research‑oriented thought-leaders for all diseases throughout our network. We are confident that they are able to communicate to us when new data is presented.

For a smaller practice that might not have a thought leader inherent in the pathways committee, other ways of staying on top of new data are needed.

Are there any concluding remarks you would like to make at this time?

Dr Schleicher: I would like to reiterate how passionate OneOncology is about ensuring that we are delivering high-value care to our patients. I want to make sure that we are never put in a situation where we are disincentivized from giving the right care to the right patient based off that patient’s cancer phenotype, even if the price is high. At the end of the day, we cannot control the cost of these drugs.

Considering pathways data in regard to total cost of care is the best way in the current to strike that appropriate balance. Over time, I hope that payers will use pathway adherence as a better metric for appropriate drug utilization rather than total cost of these drugs.