Coverage From the Rutgers Pharmacy Conference

Stakeholders Address Innovative Strategies Driving Cancer Outcomes in New Jersey

In recognizing the value-based aspects that drive patient outcomes within oncology, effective cancer care has been redefined in New Jersey to incorporate cost and health equity at the forefront of innovation.

Telehealth, in-home care, and biosimilars have all emerged as potential solutions to reduce rising financial toxicity and access concerns in oncology. But there remains a significant need for collaboration and aligned strategies to optimize population health, noted stakeholders during the 70th Annual Roy A. Bowers Pharmaceutical Conference. The theme for the 2022 conference was Innovation Through Crisis: Redefining Health Care Delivery.
At the last panel discussion of the conference, Edward Licitra, MD, PhD, chairman and CEO of Astera Cancer Care in East Brunswick, New Jersey, opened the conversation by acknowledging the utility of the recently ended Oncology Care Model in showing the level of sophistication needed to address common (dehydration, chemotherapy-related toxicity) and complex (reimbursement, social-determinants-of-health) issues for patients through a personalized manner.

“We recognized that we needed to focus more precisely on the cancer conditions themselves and how we might optimize the care for patients with specific types of cancer conditions, because in many population-based, risk-based oncology models, you have to manage populations of patients with breast, lung, or colorectal cancer,” Licitra said.

Astera Cancer Care first collaborated with Horizon Blue Cross Blue Shield of New Jersey to create an episodic care plan for patients with breast cancer. Since then, Licitra said, 18 different programs have been launched by his organization in oncology. Along with bundled payment models, he said that services typically not reimbursed by fee-for-service Medicare, such as next-generation sequencing, are also being offered to some beneficiaries.

“We think that we can actually roll up at least 50% of cancer under prospective episode-based payment arrangements, which we think then integrate with value-based care programs and population-health initiatives that will allow us to provide services to these patients, including home health services, and then ultimately control the cost of care for the provider, patient, and payer,” he said.

Steven K. Libutti, MD, FACS, director of Rutgers Cancer Institute of New Jersey in New Brunswick, added that use of bundled payment also has potential in palliative care or, as he described it, “supportive care.”

Episodic plans are typically provided to patients with early-stage disease, in part due to the minimal variance seen for these disease types. But introducing these payment models to patients at more advanced stages of disease can have a significant impact on quality and cost, Libutti said, because there is often reluctance among care teams to move to supportive care.

He noted that extending the continuum of care—from when a patient first begins treatment to when there are no more viable therapeutic options left to consider—can prove especially beneficial for providers, payers, and other care team members who may have difficulty recognizing when treatment options are exhausted and that turning to supportive care is ultimately the best option.

“At some point, going to fourth-line therapy may not be in the patient’s best interest, and understanding that and making a plan early on with the patient—how far the journey is going to go and what they may need toward the end of the journey if we’re not achieving the goals that we had all hoped for—I would love to see us flesh that out more as a part of these bundles,” said Libutti, who also serves as vice chancellor for cancer programs at Rutgers Biomedical and Health Sciences and senior vice president for oncology services at RWJBarnabas Health.

In oncology care overall, clinical trials are also a cost-effective alternative to provide standard of care at a lower cost than would be typically associated with those therapies. Findings of an analysis by Tennessee Oncology that looked at the price of care for patients across 8 different malignancies who had Medicare as part of the Oncology Care Model showed that those who were placed into a clinical trial exhibited an 18% reduction in episode costs compared with participants who were given regular standard of care.¹

Payer partnerships, along with the bundled payment models, are additionally key to covering the costs that would otherwise be placed on the patient, infusion center, and private practice, said Libutti, and increased integration of clinical trials can also reduce the use of third- and fourth-line “desperation agents” that contribute to waste.

“Not that it’s easy, but it’s one of those things that if you have an organization that can put a relatively high percentage of patients on trial, I think you should be rewarded for that because I think that there [are] benefits that would be gained by patients and also payers,” Licitra said.

With the standard-of-care drug in oncology ranging from $15,000 to $20,000 a month, Michael P. Kane, RPh, BCOP, executive director of oncology pharmacy services at Rutgers Cancer Institute of New Jersey, RWJBarnabas Health, noted that improving the eligibility criteria for clinical trials is key, as it often excludes the types of patients who typically present at the clinic.

“I would love that demographics and population-related data to be included to say, ‘Hey, you have this exclusion criteria for diabetes—why is that when half the patient population have this disease?’” Kane said.

Even in cases when there is agreement on optimal therapy for a given patient, he stressed that clinicians will still get denials when seeking approval from insurance because the drug may not be part of clinical benchmarks, such as established recommendations by the National Comprehensive Cancer Network. This occurs, he said, even though Rutgers Cancer Institute is a National Cancer Institute–designated comprehensive cancer center.

“So how do we bridge those patients from something that doesn’t have approval compendium, isn’t part of their payer policy yet, but we know it’s best care?” Kane asked. “What I think would be a better model is if you’re going to receive a drug in that fashion, there has to be a way to capture the data to learn whether it was worthwhile.”

Kane also noted that financial navigators and social workers are essential to addressing the financial toxicity related to care, as well as social-determinants-of-health issues outside the clinic, including cost of living, transportation, and food expenses.

Licitra concurred. “I think the most impactful thing that we can do is continue to have the modalities for frequent touch points for the patients. That’s everything from telemedicine to remote patient monitoring to apps because I think all of those things drive better outcomes, control cost, and improve efficiency,” he said.

Libutti added, “One of the biggest concerns I see in my own health system, and this refers to the unwillingness to get rid of old ideas, is the fact that somehow these technologies put a barrier between you and your colleagues or you and your patients. And I don’t think that’s true. I think it’s about implementation.

“Wouldn’t it be great to have real-time monitoring of some of the things that are going on with your patients so you’re not waiting every week or every month to find out how they’re doing on their agent or how they’re doing in terms of the [adverse] effects of toxicity? If I had a blank check, I would invest it in proper implementation of those technologies.”

Announced during the meeting by Libutti and Saira Jan, PharmD, MS, vice president and chief pharmacy officer of Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ), a pilot launched as partnership between Horizon BCBSNJ and Rutgers CINJ/RWJBarnabas aims to move infusion oncology treatments from the clinic to the home setting for eligible RWJBarnabas Health patients.

Along with minimizing patient travel and potential exposure to COVID-19, the Oncology Home Infusion Model seeks to develop innovative benefit design to ensure cost-effective health care delivery for patients while maintaining high quality of care in the home environment. 

Reference
1. Young G, Bilbrey LE, Arrowsmith E, et al. Impact of clinical trial enrollment on episode costs in the Oncology Care Model (OCM). J Clin Oncol. 2021;39(suppl 15):6513. doi:10.1200/JCO.2021.39.15_suppl.6513

Panel Reviews Health Inequities and Opportunities for Innovation Through Population Health Delivery

Fostering equitable health care access and quality across patient opulations warrants innovation at multiple levels of care delivery. At the 70th Annual Roy A. Bowers Pharmaceutical Conference: Innovation Through Crisis—Redefining Health Care Delivery, held September 19, health care leaders spoke on key considerations to advance population health, with hysical/behavioral health integration, accessibility of care, and insurance type among the factors influencing health disparities nationwide.

Describing the lack of research on population health, moderator Ethan Halm, MD, MPH, inaugural vice chancellor for population health at Rutgers Biomedical and Health Sciences, said recent years have seen growing interest on the topic, specifically the impact that social determinants of health (SDOH) and other potential care gaps have in leading to poor health outcomes.

“In terms of goals and approaches, the aim is to improve the health of all members of a group, not just those right in front of you in the clinic, office, or in a hospital bed. And that’s, I think, the biggest conceptual jump,” said Halm. “The idea is to measure how well we’re doing, identify gaps, and then close those gaps and intervene.”

The focus on measurement is noteworthy, he said, with data and predictive analytics of significant importance in developing interventions that are appropriate for each population, whether it is at the patient, community, or health system level.

Stratifying these interventions into inreach and outreach, in which the former describes the care strategies executed when patients are in direct proximity (eg, outpatient, telehealth, hospital visits), the latter was explained by Halm as initiatives aiming to proactively reach out to people in between visits or those who are not engaged in care. As the pandemic led to the deferral of preventive and potentially life-saving health care services, outreach strategies aim to reengage patients and providers in value-based health care, he said.

“Population health really is an important facilitated step in all of the evolution that I think people in this room are looking to see happen in health care, whether people are looking for better alignment of payment systems for fee-for-service, thinking more about total cost of care, shared risk capitation, or innovation of care delivery models,” said Halm.

Managing complex care needs was further discussed by Thomas McCarrick, MD, chief medical officer and chief medical informatics officer, Vanguard Medical Group, who spoke on his organization’s experiences in developing outreach programs for older Medicare populations who often present with SDOH issues such as food and housing insecurity and social isolation.

With COVID-19 exacerbating access to care disparities for many community-dwelling older adults, McCarrick said that a major focus for Vanguard Medical Group was ensuring these populations were properly informed and educated on their respective health risks and locations for vaccination and testing clinics.

“That was a population that we identified for us as having the greatest need and the greatest opportunity to innovate,” he said. “During the pandemic, we realized while we were trying to do telehealth visits that even though all the providers were properly trained, these homebound patients don’t have a smartphone and they [often rely] on their kids to help them—so it can be a low-quality visit.”

McCarrick said they then created a new program last year through which specialty trained medical assistants go to patients’ homes with technological devices, such as iPads or a digital stethoscope, and set up the visit in a similar way to that done in the clinic. Medical information is collected prior to the visit, he explained, and the medical assistants can see the type of home environment patients are residing in.

“We are expanding this type of visit because we think that it can actually broaden outreach to a larger population; not just the homebound, but many older patients who may become transiently homebound either because they’re acutely sick or they recently were discharged from the hospital.”

Along with physical health, Suzanne Kunis, vice president of behavioral health, Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ), addressed the access and accessibility issues affecting mental health care, which she said continues to be burdened by lack of investment and fragmented care systems.

“In the mental health and substance use space, people fall through the cracks every day,” stressed Kunis. “The message we keep trying to tell our folks is, if we do the right thing, the money’s going to follow because if we take care of people with these issues, it can affect up to 20% of the total cost of care. The other piece of it is it can no longer be diabetics to the right and schizophrenics to the left. The fact is, many times they’re the same person.”

Through their recently developed integrated system of care program designed specifically for beneficiaries with mental illnesses and substance abuse disorders, Horizon BCBSNJ aims to integrate physical and behavioral health care in a value-based framework that also accounts for the SDOH challenges associated with adverse health outcomes and subsequent cost burden.

The model places greater responsibility on community-based providers to be the “quarterback” in managing the holistic care plan and directing patients to needed care services, said Kunis. After 6 months of implementation, she highlighted the significant impact the model has shown on care outcomes, including a 21% decrease in emergency department visits and 27% lower costs of care.

“We didn’t want to wait and say, ‘Let’s see this out for a year and a half’—we have enough faith in this model that we began to roll it out across the state of New Jersey. So, in every county in the state by the end of this year, we will have this model up and running.”

As risk sharing is being shifted through value-based frameworks from health systems to individual physicians, Myoung Kim, PhD, vice president, population health account management & health economics and outcomes research, Novartis, noted the impact this will have on the pharmaceutical industry whose role is to translate how innovative medicines affect health outcomes.

The process of health care delivery, including payment and financing, is key in this process of translation, said Kim. “If we’re going to be held accountable for outcomes, we have to be given the opportunity to learn the delivery system and the opportunity to be at the table to figure out the better solutions as to how to better deliver care to patients at the population level,” she added.

The need for greater use of real-world evidence and diversified study cohorts was also referenced by Kim to promote equitable health care and to reduce the lag time created when these factors are not accounted for at the onset of clinical research.

“We know a lot about the drug when it was used in an ideal setting, but we [may] have no clue as to whether it delivers [for all populations] and the disadvantages or advantages it has, where it has to be used, and all these things have to be rapidly learned. The faster we learn, the better off we would be,” she concluded.

“The better we can align innovation resources with the true global health burden, including health care delivery gaps and payment—I think we all win together.”