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The financial stats of healthcare are all too familiar – the 18% of GDP, $3 trillion spend, and the $11k per capita cost are frightening to consider. We are on an unsustainable financial trajectory, as those numbers are projected to increase. The costs for cancer care, which include both medical services and drugs, are no different. In 2015, national costs for cancer care were estimated to be $190 billion and just 5 years later, in 2020, the costs ballooned to $209 billion. The 10 percent increase is primarily attributed to the aging and growth of the U.S. population.
As oncology practices transition to value-based care, they are challenged to take on more holistic responsibility for their patient. Fortunately, there are many examples of practices participating in CMS’ Oncology Care Model (OCM) that have made impactful workflow changes to achieve cost and quality improvements. The OCM was the first cancer-specific alternative payment model for Medicare recipients as well as Medicare’s first APM for outpatient specialty medicine. Despite several practices succeeding in the OCM, many have not. At this point, the overall results of the APM have been underwhelming. Since the OCM was originally implemented in 2016, the program has led to a $155 million net loss to Medicare. While originally set to expire this summer, to be replaced by Oncology Care First (OCF), the date was pushed back by a year. CMMI can apply lessons learned when launching the OCF, and Texas Oncology is where they can find oncology care that is thriving in the race to value.
Our guest this week is Debra Patt, M.D., PH.D., MBA, a practicing oncologist and breast cancer specialist in Austin, Texas. Dr. Pratt serves as the Executive Vice President for Public Policy, Payer Relations, and Strategic Initiatives at Texas Oncology, a network of 210 sites of service and 490 doctors, serving half of the cancer patients in Texas. In this role she advocates for effective cancer policy at the state and federal level, and advises on strategy for various initiatives, such as telemedicine, optimizing growth and development of advanced practice providers, development of service lines, informatics initiatives and contracting. Her research is in clinical decision support, predictive analytics, telemedicine, health economics and outcomes, tools for patient symptom management and quality improvement. As an expert in healthcare policy, she has testified before Congress to protect access to care for Medicare beneficiaries. She is the editor-in-chief of the Journal of Clinical Oncology- Clinical Cancer Informatics.
01:45 Background information on Dr. Debra Patt and her work in Value-Based Oncology Care
05:00 The Country’s Financial Burden of Cancer Care – Why we need to transition from Volume to Value
07:00 The need to anchor our expectations for value differently based on the aging of the population and the advancement of treatment
08:15 Investments inpatient care and drug research is more like a “mortgage” instead of paying “rent”
09:00 How cancer care is bankrupting patients due to out-of-pocket burden
09:25 Many forms of cancer are now being treating like an acute illness instead of a chronic disease akin to HTN or diabetes
09:45 The societal and economic benefits of people living longer upon the initial diagnosis of cancer due to advances in care
10:10 Referencing the book, “The Great American Drug Deal: A New Prescription for Innovative and Affordable Medicines”
10:40 Other investments, outside of new innovations in drugs and therapeutics, that are still needed in value-based oncology care
12:00 The Oncology Care Model (or OCM) — the first cancer-specific alternative payment model for Medicare recipients
12:45 The underwhelming results of OCM, a $155 million net loss to Medicare, largely due the model’s complexity
14:00 Correlating the assessment of OCM’s success to the value equations, i.e. it is not just about cost containment
15:00 The implementation of an individualized treatment care and coordination plan (an example of OCM success)
15:30 Investments in nurse navigators, 24/7 EHR access, just-in-time symptom control, nursing triage systems, patient-reported outcome measures, and biosimiliars
16:30 90% utilization of biosimiliars as key measure of value-based success
16:50 Depression Screening and discussion of Advanced Directives as another area of focus within the OCM
17:20 Diminishing information asymmetry between doctors and patients – a key improvement resulting from OCM!
17:50 Financial Counseling for patients to help them manage their journey in cancer care
18:35 Using lessons learned from OCM to enter into value-based arrangements with commercial payers
19:00 The transition gap between the OCM and the Oncology Care First (OCF) model
19:50 Potential improvements in OCF (building on lessons learned from OCM), e.g. symptom management and patient-reported outcomes
21:00 The controversial, mandated Radiation Oncology (RO) Model that will address the current flaws in reimbursement for radiation therapy
23:00 “Radiation Oncology is ripe for value-based care transitioning, but the currently proposed RO model has several challenges.”
24:00 Dr. Patt explains why a voluntary payment model for value-based radiation oncology is the more prudent course of action in the current environment
24:30 Patient radiation dosing exceptions (the need for specialized treatment and higher fractionations) are incredibly important when considering how to spare organ toxicity
25:30 How specialized radiation oncology treatments can pose financial risk to an organization if participating in a mandated payment model
25:50 The distress experienced by oncology medical practices due to COVID-19 and the current shortage of nurses (why we need to reconsider mandated models)
27:20 “Community oncology practices are overwhelmingly the lowest cost and highest value site of service where patients can receive cancer care.”
29:00 How interdisciplinary team-based care supports reduced hospitalizations, reduced ED visits, increased adherence to treatment plan, and better patient experience
30:00 “Improving the health literacy of patients is critical to cancer care.”
30:30 The use of telehealth and virtual care delivery to improve palliative care services
31:30 Integrating social workers, nutritionists, palliative care, and psychology services within a community oncology practice
32:30 Virtual support groups for patients to help them deal with social isolation during the pandemic
33:20 The importance of communication between interdisciplinary providers in a value-based oncology practice (“the huddle”)
37:00 More complicated treatments in cancer care that require patients to have heightened awareness in toxicity and knowing how to navigate treatment optimally.
38:30 Financial Toxicity in Cancer Care – the financial burden of cancer treatment for an individual patient may be $20-30k per year!
40:20 Financial counseling for patients to better understand out-of-pocket burden and how best to augment financial support
41:20 How imatinib (the treatment of chronic myelogenous leukemia) shows us the impact of price sensitivity in cancer treatment
41:50 The need for reform in insurance products that leave patients exposed to significant levels of financial risk with limited coverage
42:40 The need for reforms in the Medicare program to optimize cancer treatment and survivorship options
44:00 Clinical Pathways – how value-based care models are standardizing cancer care with pathways adopted from the National Comprehensive Care Network (NCCN)
46:00 The importance of “nudges” in clinical decision support
47:00 Referencing the book “Nudge: Improving Decisions about Health, Wealth, and Happiness” and how it promotes choice architecture in making good, autonomous decisions
48:30 “Not all pathway systems are the same.”
49:30 The difference between Biologics (complex medicines made from living cells or organisms) and Biosimiliars (a biologic that is highly similar with no clinically meaningful difference)
50:30 Dr. Patt discusses the role that biosimilars play in value-based oncology care
52:30 Advanced Care Planning can consistently provide high patient and family satisfaction, reduce hospitalization by nearly 50%, and decrease costs in the last year of life by 20% to 25%.
53:40 Dr. Patt discusses how Advanced Care Planning helps prevent ineffective interventions near the end of life and the role it plays in human-centered care delivery and value-based oncology.
55:30 Referencing Iris Healthcare (see prior Race to Value episode with Dr. Stephen Bekanich)
56:00 Health Equity and Racial Disparities in Care – 34% of all deaths from cancer in those aged 25 to 74 could be prevented by 2035 if disparities in access to care were eliminated!
57:30 Dr. Patt discusses how socioeconomic challenges typically manifest into inadequate and unfavorable treatments in both cancer care and primary care
60:00 How COVID-19 has greatly altered the cancer care landscape
63:00 The delays in cancer screenings during the beginning of the pandemic and how that presents challenges to current operating capacity for many practices