Hollywood, FL—Contracting in oncology has become a more complicated process, now that it involves many entities beyond physicians and payers. Dawn G. Holcombe, MBA, Vice President, Strategic Relationships, Florida Cancer Specialists, Sarasota, FL, described the scenario at the 3rd Annual Conference of the Association for Value-Based Cancer Care.
The different perspectives from payers and providers make contracting difficult. Payers want to reduce variation and cost, and they expect providers to be good business partners. Providers want to give patients with cancer help and hope, and although they believe in evidence-based medicine, they also have to stay in business. Finding the common ground can be a challenge.
The result is “dissonant messaging,” Ms Holcombe said (Table). At the end of the day, “it is about the management of costs and care for efficiency and effectiveness—seen from each perspective.”
Contracting in oncology used to be between payer and provider, but it is more complex now, because it also involves hospital systems, pharmacy benefit managers, specialty pharmacy, retail infusion clinics, and others. Layered upon this are navigators, disease management companies, oncology management companies, and the like.
“With some of the arrangements we are seeing now, you may not be at the table with the same people you are used to,” Ms Holcombe noted.
Among the issues that influence contracting are the role of care navigators and case managers; various channels for treatment approval; data and their sources; quality and how to define, measure, and fund it; and pay for performance and how to determine it.
“We used to just talk fee schedule, rates, drug fees. Now we have a laundry list of things to deal with, and it’s not just you driving the choices in medical decision-making. Shifting sites of care also affect the physician’s direct involvement in negotiations. And with less money available, retooling is critical,” Ms Holcombe said.
Issues surrounding cost are not just about drugs anymore but the total cancer spending, which includes physician services and drugs, diagnostics, drugs prescribed outside of the physician office, hospital care, end-of-life care, and other services. The continuum of care should be evidence- and treatment-focused, moving away from a single cost focus (eg, prior authorizations, step edits, preferred formularies, fee schedules).
Going forward, payers have a long list of drug management expectations for physicians or specialty pharmacy. This list includes clinical assessment, counseling, education, outreach, monitoring, and reporting—with proper documentation. Providers will need to carve out policies pertaining to all these areas.
“Keep it simple,” Ms Holcombe concluded. “Build relationships and future projects after you establish trust and communication.”
Address pressure points—the common practices and services that can be cataloged, measured, valued, and marketed, such as emergency room and hospital visits avoided, conversations about end-of-life care conducted, and disease and symptom management steps documented.
Reform in oncology will require a change in perspective, away from drug costs to total spend. Collaboration will be increasingly required, because data will be “in different pots,” Ms Holcombe pointed out. “No one of us can develop a solution in and of ourselves….Collaboration is the fastest route to success, but trust is needed.”
