Changing Culture and Finding Champions: Licitra, Arrowsmith Discuss Value-Based Care in Oncology

Implementing value-based care in an oncology practice is a journey, one that demands commitment from every member of the organization and a culture shift that takes time, according to 2 practice leaders taking part in the OneOncology Physician Leadership Conference in Nashville, Tennessee.

Edward Licitra, MD, PhD, who is CEO of Astera Cancer Care, based in East Brunswick, New Jersey, and Edward “Ted” Arrowsmith, MD, of the Chattanooga office, Tennessee Oncology, shared ideas during a panel discussion at the OneOncology Physician Leadership Conference, held Friday through Sunday in Nashville, Tennessee. Sheri Chatterson, MSM, MBA, CFHP, vice president of payer relations, led the discussion.

Chatterson started by asking how practices arrived at value-based contracts, which are needed to implement value-based care. Both Tennessee Oncology and Astera have reached value-based contracts with the Blue Cross Blue Shield (BCBS) entities in their respective states.

“When we do the right thing, we're always focused on doing the right thing for the patient, the rest of it will follow along,” Licitra said. “We’ll get alignment of incentives, we'll get better outcomes, we'll build a better model.”

He acknowledged that value-based care can mean different things to different people. On one end of the continuum are those who start by setting up an oncology medical home, offering Humana’s model as an example. “That’s really the foundation,” Licitra said. “If you don't build a strong foundation, and if you don't build a comprehensive value-based care home that evolves over time and gets better based upon all the experiences that happen…you really don't have much.”

On the other end of the continuum, value-based care moves toward capitation, which could be “transformational,” but extreme care is required. Shared savings models are retrospective in nature, including the Oncology Care Model (OCM), which started as a 1-sided risk model to train practices and evolved into a 2-sided risk model.

Arrowsmith said value-based models have evolved because cancer care has become expensive, “and there’s not that enthusiasm for just writing a blank check to pay whatever it is that you do.” Payers, he said, want to see constructs such as pathways to bring more standardization to care, to drive down costs, and to prevent unnecessary emergency department (ED) visits and hospitalizations. Tennessee Oncology was able to reach a contract with BCBS of Tennessee, the state’s largest payer, which is “towards the beginning of the continuum,” and requires certification of lessons learned over 5 years and proof of quality care.

From there, Arrowsmith said, Tennessee Oncology was able to “get into the room” with BCBS to negotiate a contract that spells out what the practice can and cannot control, specific targets, and margins to beat.

Chatterson asked, what are relationships with vendors like under value-based care?

Licitra emphasized the need for partnerships. “Unless you have a willing partner that's you're ready to sit down, roll up your sleeves and actually work together toward a common objective, none of these things ever work,” he said. In New Jersey, Astera was fortunate to have a willing partner with Horizon BCBS, and the 2 entities started 4 years working on cancer episodes. “We started out with medical oncology, we then added radiation oncology and breast surgery,” Licitra said.

The episodes had to be well-defined by certain lengths of time, and Astera had to be able to construct the episode for each patient that “didn’t have to pay attention to fee-for-service.”

Licitra said payers like this approach because it offers a deeply discounted rate compared with similarly bundled services. “It actually reduces a lot of the burden on both the patient and the physician, because they're not worrying about getting things approved.”

Arrowsmith said value-based contracts can customized to highlight a practice’s strengths and minimize the weaknesses. Whereas Astera has a breast cancer model that includes its breast cancer surgeons and radiation centers—and can include lower charges for those services than the payer would see from a hospital—Tennessee Oncology leaves those items out.

Next, Chatterson asked what it takes to change a practice’s culture.

“Culture isn’t one big thing you do,” Arrowsmith said. “It’s a thousand little things you change over time.” Doctors and nurses want to do the right thing—it’s about thinking of ways to incentivize all the little things that improve care and patient experience.

It’s not simple, Licitra said. “If it was just a handful of things, everyone would do it.”

The shift in mindset, he said, goes beyond optimizing clinical variables to a change in approach that goes beyond avoiding doing something inappropriate. “Once you enter value-based care arrangements, the physicians have to think about the world of medicine very, very differently.”

And it’s not just the physicians—the triage nurses, the chemotherapy nurses, and the rest of the staff all must think through the consequences of what their decisions might mean that day and several days or months ahead. “It takes a lot of work to make sure that you continuously provide physicians with data. You have to provide them with reliable data, because they all say that your data is wrong. Provide us with reliable data and make sure that before you go into the meeting, that your data is actually correct.”

So, where does a practice begin?

“Find a champion, or find a few champions for value-based care,” Licitra said. Without that lead physician, administrator, or pharmacist who is passionate about making the culture change and the execution work—about doing the right thing—it will be hard to evolve.

“You think about it as it's kind of like a challenge,” he said. “because there's a lot of work that has to actually happen to be successful. Without the proper leadership and the proper champions for it, I think it's tough to do.”

Arrowsmith said to identify the key levers, such as keeping patients out of the ED, which can make a significant difference. And, he said, “Don’t give up.”

Some ideas that practice members think are great ideas might fall flat with payers, Arrowsmith said, but it’s important to keep talking. It took Tennessee Oncology 5 years to reach agreement with BCBS of Tennessee.

The physicians said starting with a framework the payers are already using and adapting an idea to fit that model works much better than presenting something completely different. And once a practice has implemented the first model, Licitra said, “the rest are a lot easier.”