The past decade has brought remarkable innovations in cancer care, resulting in reductions in the incidence and death rates for many cancers, as well as major advances in cancer treatment, research, and diagnostic technologies1. The 21st Century Cures Act of 2016, which created funding for the cancer Moonshot Initiative, represented a major step toward accelerating cancer research and seeking cures1.
Most importantly, new models of care and payment delivery, along with innovations in treatment and technology, have prompted a new focus on value-based care to better meet the needs of people with cancer. Areas of oncology that have seen major shifts include:
- Consolidation The oncology practice landscape has been transformed through the widespread consolidation of oncology practices into oncology groups and integrated delivery networks (IDNs.)
- Clinical Pathways As the traditional fee-for-service payment system moves toward newer payment models that emphasize value, this has also prompted an increase in the use of evidence-based pathways to control costs and improve outcomes.
- Patient Experience Patient-centered care has also shifted to the forefront as an important quality indicator of value-based care.
At the same time, there has been growing alarm among oncology stakeholders that the staggering costs associated with cancer treatment place an enormous burden on the healthcare ecosystem, especially in comparison with other diseases. Ensuring patient access to affordable, high-quality care remains a challenge1. As the costs of patient care escalate, and new, high-priced therapies emerge, the need for value-based oncology has never been more urgent2.
There is broad consensus among cancer clinicians and policy-makers, representing both community-based oncologists and designated cancer centers, that value-based oncology must be structured to
- Address the rising costs of cancer treatment and related care, including survivorship
- Ensure that payment models enhance access to coordinated, high-value, patient-centered care1
- Achieve best practices for oncology clinical pathways that balance innovation with patient access3
- Promote shared decision making between patients and providers
Value-Based Payment Models
To reign in the costs of cancer, while advancing quality care, several models of value-based payment have been introduced. These include financial incentives for adhering to clinical pathways, patient-centered medical homes (PCMHs), bundled payments, and specialty accountable care organizations (ACOs). The Centers for Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) introduced two reimbursement paths for oncology physicians based on incentives and rewards for quality
- The Merit-based Incentive Payment System (MIPS) keeps the base fee-for-service payment while consolidating three existing incentive programs rewarding performance and outcomes
- Advanced Alternative Payment Models (APM) such as the Oncology Care Model (OCM), based on quality as opposed to the traditional fee-for-service model. APMs are available to physicians who join a patient-centered medical home, a bundled-payment model, or the Medicare Shared Savings Program4
As these new payment models evolve, they will be under increasing scrutiny to demonstrate success in reducing cancer costs, along with other cost efficiencies, such as the use of pathways and better patient management5.
The Role of Oncology Clinical Pathways
Oncology clinical pathways (OCPs) were developed with the goals of managing the use of cancer drugs, streamlining variations in treatment, and improving quality of care, while containing costs6. Driven by the consolidation of oncology practices and the shift to value-based reimbursement tied to the use of OCPs, there has been a 42% increase from 2014 to 2016 in their use1. From a value-based perspective, high-quality clinical pathways can promote cost-effective, evidence-based care in an increasingly complex treatment environment. They also ensure that the cancer diagnosis and treatment are being appropriately addressed and managed. However, not all pathways are created equally. Pathway vendor organizations may develop OCPs based on whether their customers are health plans or providers; each of whom may have different goals and criteria for treatment decisions3. There is also some criticism that pathways may encourage a “cookie cutter” approach to treatment and limit access to more innovative therapies7. In 2016, the American Society for Clinical Oncology (ASCO) created a Pathways Task Force to examine the role of pathways in oncology, with the ultimate goal of better understanding the features of high-quality OCPs and in order to advance the delivery of high-value care8.
Patients at the Center of Value-Based Care
There is an overwhelming consensus that comprehensive, patient-centered, multidisciplinary teams provide optimal value-based care across the cancer continuum. Today, designated cancer centers, IDNs, and many provider groups use care teams made up of specialists, such as radiologists, oncologists, and pharmacists, as well as case managers/nurse navigators and social workers, to maximize treatment continuity, symptom management, and quality of life resources, including financial and community supports.
The ability to access the internet and related apps for information and tools to help cope with a cancer diagnosis has made patients more technologically savvy and empowered than earlier generations9. Still, cancer remains an overwhelming, frightening, and, in some instances, devastating diagnosis. During the cancer journey, it is imperative that patients receive the information and support they need from providers and care teams to assist in their own care and treatment decision-making. The ultimate test of value-based cancer care will be the ability of patients to access affordable, high-quality care that is appropriate for their cancer diagnosis and stage, enhances their experience, and enables them to share in their treatment decision-making.
- The State of Cancer Care in America, 2017: A Report by the American Society of Clinical Oncology. The American Society of Clinical Oncology. http://ascopubs.org/doi/abs/10.1200/JOP.2016.020743?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&. Accessed March 25, 2018.
- Value-Based Oncology Conference. The Institute For Value-Based Medicine (IVBM). http://www.ajmc.com/value-based-institute/interviews/vbonc-conference-workshop. Accessed March 25, 2018.
- Oncology Clinical Pathway Best Practices: Understanding the Current State of Pathway Development, Implementation and Evaluation. Feinstein Kean Healthcare. http://www.turningthetideagainstcancer.org/-/docs/T3_program_021317_v2.pdf. Accessed March 25, 2018.
- Value-based Payment Models in Oncology: Will They Help or Hinder Patient Access to New Treatments? The American Journal of Managed Care. http://www.ajmc.com/journals/evidence-based-oncology/2017/april-2017/value-based-payment-models-in-oncology-will-they-help-or-hinder-patient-access-to-new-treatments. Accessed March 25, 2018.
- The evolution of oncology payment models: What can we learn from early experiments? Deloitte Development. https://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-lshc-evolution-of-oncology-payment-models.pdf. Accessed March 25, 2018.
- Care pathways in US healthcare settings: current successes and limitations, and future challenges. American Journal of Managed Care. https://www.ncbi.nlm.nih.gov/pubmed/26799125. Accessed March 25, 2018.
- Clinical Pathways: Recommendations for Putting Patients at the Center of Value-Based Care. American Association for Cancer Research. http://clincancerres.aacrjournals.org/content/23/16/4545.long. Accessed March 25, 2018.
- Oncology Clinical Pathways: Charting the Landscape of Pathway Providers. American Society of Clinical Oncology. http://ascopubs.org/doi/full/10.1200/JOP.17.00033. Accessed March 25, 2018.
- Changing Trends in Oncology Practice: Value-Based Care and an Empowered Patient. American Journal of Managed Care. http://www.ajmc.com/conferences/accc-2018/changing-trends-in-oncology-practice-valuebased-care-and-an-empowered-patient. Accessed March 25, 2018.