Payers’ Perspectives on Cancer Care

December 2020, Vol 11, No 6

In an environment of increasing vertical and horizontal integration in healthcare, are new value-based care models in oncology—such as the Centers for Medicare & Medicaid Services’ pilot payment project, the Oncology Care Model (OCM)—working? Five years from now, will we still be talking about efforts to go from volume to value using alternative payment models?

Those were some of the key questions posed to leading representatives from payer groups of all sizes, ranging from regional health plans to the biggest national payers, at the 10th Annual Summit of the Association for Value-Based Cancer Care (AVBCC) in 2020. The discussion was moderated by Michael Kolodziej, MD, FACP, Senior Advisor, ADVI Health.

Many of the participants in this discussion agreed that the OCM, which currently involves approximately 25% of oncology practices in the United States, is likely not scalable beyond the regional level.

“I think we need a solution for America, not the best 25% of practices,” Dr Kolodziej said.

“The concept of value-based care still has a pulse in oncology, but it needs to be parsed out into engagement with large volumes of patients,” agreed Roger Brito, DO, Division Head, Enterprise Oncology, CVS Health.

Other hot topics included whether to eliminate buy-and-bill; shifting value-based models from managing hospital and emergency department admissions to serving as the major driver of oncology spending, namely, drug costs; the high cost of end-of-life care; and the paucity of evidence driving 3 and 4 lines of therapy and beyond in onoclogy.

“The game needs to change,” said Dr Brito. “The guidelines are pretty clear for early-stage therapy and usually involve the same regimens. In late-line therapies and very advanced cancers, quite frankly, we need to do better. That’s where there’s a real opportunity to have discussions about palliative care and improve on care delivery in the US.”

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