Optimal Oncology Alternative Payment Models, October 2018
As Aviki et al. recently noted in a systematic review of alternative payment models (APMs) in oncology, despite the growing number of such models, “there is limited evidence to evaluate their efficacy.” Indeed, we do not yet understand these models’ impact, whether they will ultimately prove to be sustainable, and whether they will effectively shift cancer care to a value-based paradigm. As such, some stakeholders believe there is a need for a continuous learning platform to rapidly identify failures and successes, as well as a need to collaboratively solve the ongoing challenges these models face.
To respond to these needs, a group of oncology care leaders has formed an advisory council to progress oncology APMs. Following a series of initial discussions in mid-2018, the council held its inaugural meeting on September 13 in Washington, DC, to focus on topics that the group collectively prioritized. Of these topics, data—which many see as the foundation for success in APMs—was a focal point of the meeting’s agenda and factored prominently in the issues discussed:
Exploring the path to two-sided risk. Participants assessed the level and types of risk that may or may not be appropriate for providers in APMs. They debated whether oncologists should be held financially accountable for costs outside of their control, such as drugs and medical costs that are not cancer related. Because some APMs are undoubtedly going to continue to include these elements, participants also explored the efficacy of tools to mitigate providers’ risk, such as reinsurance/stop-loss products. Following a conversation with expert guests, some providers were dismayed to learn that the cost of a reinsurance/stop-loss product for an oncology population—which, by definition, is high cost and risky—was likely to be very high. Some, however, retained interest in exploring how these products could be effectively deployed in their models.
Supporting all sites of service. Participants explored incentives outside of risk-based APMs that could make more providers accountable for delivering high-quality, value-based care. They focused on approaches to support community practices in making this transition. Some participants pointed to the benefits of closer, more collaborative support from payers; such support could include better provision of data, customized incentives and care-coordination fees, and referrals to third-party quality-assessment programs. Some remain concerned, however, that the benefits of these incentives do not justify the cost of providers’ investment. Others recommended clinical pathways tools, although some cautioned that even these come at a price tag and require approximately 80% adherence to make a meaningful improvement in quality and cost containment.
Addressing the data conundrum. Participants discussed how to better enable providers’ access to high-quality clinical and cost data. Some emphasized that in APMs, providers need to focus on better using the data they already have, much of which lies in claims. Others focused on the increased burden that data input places on providers and brainstormed new business models for incentivizing data creation in electronic health record (EHR) platforms. They proposed potential partnerships where manufacturers could pay for data input, and in return, would be guaranteed an early look at the data generated.
Introducing emerging oncology APMs. Some participants briefed the group on new oncology APMs they are developing, all of which will rely heavily on data. One model will focus on using genomics to make better-informed transitions to palliative care. Another localized model will engage self-insured employers and leverage sophisticated data analytics from payers. Finally, another will create more granular—and, presumably, accurate—payment categories through a state-of-the-art cognitive computing platform.
Plotting the way forward. Participants identified several topics they would like to see the council focus on in the future. Foremost among these was a continuing focus on data, including the need for oncologists participating in APMs to have a consistent set of meaningful EHR fields, and ways to reduce the time and resource burden on providers for data input, procurement, and utilization. Several participants called for continued examination of how best to structure risk in APMs and tools to manage it. Other proposed topics include taking a more multidisciplinary look at oncology, identifying good practices that APM models can employ to empower all sites of service, and assessing how emerging technologies like blockchain and telemedicine and trends like home-based care may impact APMs.
In closing, participants reiterated the need to learn more about existing models and for continued experimentation in oncology payment reform. The council will continue to serve its members by addressing these goals in 2019.