AJMC® INTERVIEWS: Faculty From the Institute for Value-Based Medicine

Jeffrey Lowenkron, MD, MPP, Chief Medical Officer, The Villages Health

During your time at The Villages, have you observed progress in patient empowerment over care planning and more use of palliative aid to avoid unnecessary invasive treatment at the end of life?

I would say, unfortunately, no, and it’s not because we don’t have time. Any time you look at anything that’s been evaluated over the last couple of decades related to end-of-life care, it’s not the patients. The patients have already thought about it. They know what they want. They’re really hoping somebody would ask them. We never ask them. In primary care, I don’t know the numbers now, [but] it used to be about 4% of the time we asked them, even though 80% of the time they thought about what they wanted and knew. I would say the only group that’s probably worse at doing advanced directives and palliative care than primary care is oncology. For the folks that have oncology problems, the likelihood that they’ll get palliative care at the right time or even hospice at the right time, I would say it’s unfortunately delayed.

Is the expansion of Medicare Advantage a plus or a minus for oncology care in your view?

I think the expansion of Medicare Advantage, it’s always a plus for the patient. Because what Medicare Advantage does, as opposed to the fee-for-service world, is it links and aligns patient outcomes with care delivery. As patients do better, the care delivery systems do better, and as patients do worse, the care delivery systems do worse. In the typical fee-for-service model, generally the care delivery system can do really, really well, and the patients may do very, very poorly. They don’t have to align. From the perspective of the patients, it’s always a better care model and payment model to be in Medicare Advantage than traditional fee-for-service.

From the oncology perspective specifi cally, there are going to be some challenges because obviously with the expansiveness of very expensive medications in the oncology world, the diffi culty of fi guring out how to pay for those is a real challenge. I can’t tell you whether it’s going to be better or worse for them over time.

Maen Hussein, MD, Physician Director of Finance, Florida Cancer Specialists

What will CMS’s proposed change in the way Medicare Advantage pays for hospice mean for community oncology practices?

I think that hospice is being underutilized in caring for our patients. There is this mentality that hospice means that the patient is going to die very soon. That’s really not true. There are more data showing that palliative care and hospice actually help improve the quality of life, and in some cases, even survivorship. I believe that the new changes will help and encourage the oncologists to bring up that topic sooner than later, and maybe help the patient accept that concept, and change the culture to understand that being under hospice care doesn’t mean you’re dying tomorrow. The indication for hospice, if the patient has survived, it’s less than 6 months, and that actually can be extended. It doesn’t mean that you’re even dying within 6 months, but that’s usually the period and if the patient lived to 6 months, you can even extend that. That will encourage the physicians to approach the patient sooner than later; talking about the option of hospice. I can see that culture change. I’ve been practicing here for almost 15 years now. It was much harder to talk about hospice before than now, especially when you explain to the patient that this is not the end, you’re not giving up. But it’s a way to focus on your pain and discomfort and still allow for some palliative therapies. A lot of hospice now are [willing] to pay for radiation therapy as palliative [care], or even sometimes some forms of chemotherapy.

The Oncology Care Model (OCM) has been criticized for failing to adequately account for high-cost drugs for some patients. Have you seen improvements in the proposed Oncology Care First model and which proposed change do you believe is the most important?

I think it’s still early to judge if the changes [will] have an impact. I think one of the things that seemed to be promising is that they have the risk assessment for each cancer, so they have the risk stratifi cation. That might help in the future to assess for each type of cancer, how much it will cost to treat those patients. That will help in the bundled payment in the future.

Rebecca Kirch, JD, Executive Vice President, Health Care, Quality and Value, National Patient Advocate Foundation

What obstacles continue to prove an issue within oncology? What further research is warranted to address these issues?

There are some interesting challenges in the form of language barriers, and old habits that die hard. [At the meeting of the Association of Community Cancer Centers,] we talked about the importance of integrating palliative care, and the fi rst question was, “Well, who provides that?” Depending on when you were trained in your practice, you might have learned palliative care as something diff erent from what it is today and what the evidence shows. So today, what palliative care is, is an essential aspect of good quality cancer care from diagnosis onward to optimize quality-of-life.

Whose job is it? It’s everybody’s job. Every clinical encounter needs to include some aspects of helping with care coordination, identifying what’s bothering the patient and caregiver most, because they’re an essential unit of care. The opportunity we have to use the skilled communication that is sort of at the core palliative care principle for all frontline clinicians to be equipped and confident and engaged in doing, I think will make a significant diff erence for how value-based care unfolds, how payment reform happens, how the lived experience plays out for patients and families to be a better one, irrespective of the prognosis of the trajectory.

If we emphasize the importance of those skills, and the opportunities to address financial impairments and functional impairments through navigation to these services that people need that focus on what they say matters to them, then we’re delivering truly person-centered care and the promise of what that can be. If we keep emphasizing diseasedirected treatment without thinking about quality-of-life, and the person beyond the disease, we’re going to fall short of all of those goals that we all hold dear.

Michael Diaz, MD, President of Community Oncology Alliance and Assistant Managing Physician at Florida Cancer Specialists

In its response to the Oncology Care First request for feedback, COA recommended a delay in the start of the successor model to January 1, 2022. How will having more time in the OCM benefit practices?

Well, there are several reasons. First of all, 2021 is less than a year away, and we don’t have details on this new model. In order to have practices evolve, change, and implement new processes — and I think that’s one of the key things here — there are a lot of new fundamental components that are diff erent than the Oncology Care Model (OCM). We want to make sure that practices have adequate time to learn, understand, adapt, and modify. We’re wanting to extend the Oncology Care Model in essence, to actually delay the initiation of the Oncology [Care] First model. That’s the most important thing. Some people will say, “Well, why can’t you just complete the Oncology Care Model, delay the Oncology Care First model 6 months to a year?” Well, all the practices already had this infrastructure set up for this type of system process. We have care coordinators, we have layers and layers of new systems that we’ve developed to be able to participate in these value-based care models, these alternative payment models. Without participating in a model, you can’t keep and maintain your fundamental infrastructure. The majority of the practices, we feel, would experience some financial hardships trying to maintain those components of their practice if they’re not participating in them all. We just think that it would help ease a transition.

Another more significant reason has to do with the fact that the Oncology Care First model, when you start in it, right now, the way it’s designed, you start off in a 2-sided risk. We would like for as many community oncology practices to be able to participate in this, and not all are participating in the 2-sided risk of the Oncology Care Model. We just think a delay would allow more time to allow more practices to evolve to be able to participate.

Are you receiving any early feedback from practices that have moved to 2-sided risk?

We have been hearing from other practices. I think that because right now we’re still getting feedback from the later performance periods, before people had to switch in 2-sided risk, we’re getting mixed results, because not everybody is in 2-sided risk in the first place. Those that have gone to 2-sided risk, some are doing extremely well. I have not heard from those that are in 2-sided risk and have not done well. The only other things that I have heard is that as we proceed, and we get data from subsequent pay periods, things are changing and people aren’t performing as well as they thought they might. They’re not sure why but there’s just a delay in the time required for the feedback. I haven’t heard anything from the practices since we had to decide to accept the 2-sided risk model for this period, but I’m sure that we will hear more as time evolves. That’s another reason why it wouldn’t necessarily be a bad idea to sort of delay the initiation of a new model, because the amount of time in between the period during which we’re taking care of patients and the time we get the feedback, there’s such a delay. It’s a little diffi cult to make changes very quickly, because we just don’t get the information very quickly. We just need the time to improve our processes. If we could narrow down the time interval from when we are seeing patients in the performance period to the time we get the information results and understand why we did how we did, if we can get that time interval narrowed down, then it would probably be easier to transition and evolve at a faster rate.

Cancer Specialists can share with other community practices that are moving to alternative payment models?

What are the most important lessons from the OCM that Florida

I thought about this because we’ve been working at this very diligently for the past several years. I would say, it takes a lot of collaboration. You need to network with the other practices involved. You need to share ideas. You need to network with specialists that understand the data that you’re receiving from CMS. Because whenever you get the data, it’s not very easy to interpret or understand, so you need to work with a specialist that can help sift through all the details so that you can understand why your practice performed the way that you did. Until you know that information, it’s very difficult, very difficult to make improvements. Networking, working with experts, I would say those are the main things. Also, you have to get the physicians involved and you have to get their buy in. They have to really understand the importance and believe in it and understand why they’re doing it. I think that if you get all those major components aligned, along with having very good management, practice management that can sort of glue all that together, I think that helps to optimize success in any form of alternative payment model including Oncology Care Model.

Lucio Gordan, MD, President & Managing Physician, Florida Cancer Specialists

In your opinion, does the proposed Oncology Care First model go far enough to address concerns that the OCM did not adequately reimburse practices for high-cost therapies? Why or why not?

The Oncology Care First model remains very diffi cult to understand, in my opinion. I think Community Oncology Alliance and others have sent several initial suggestions and recommendations to CMS, CMMI (Center for Medicare and Medicaid Innovation) as t o how to design Oncology Care First. I am not convinced yet that Oncology Care First truly takes into account the necessary elements, including high-cost drugs. I think we lack understanding as far as the details, as to how this will be operationalized. We really have embraced the Oncology Care Model. We do think that value-based care should obviously continue in cancer care in the United States. It is just taking maybe too quick of a step from moving from the current Oncology Care Model to Oncology Care First. There are a lot of things that need to be understood and the details need to be ironed out for us to truly embrace this as a solution for us.

Have you seen any shifts that suggest payers are recognizing cost differentials between hospital and community oncology settings in cancer care?

I have seen a significant improvement in understanding of the site of care issues as far as cost, as we compare hospital systems versus community oncology. Išhaven’t seen enough action and results yet. Clearly, the payers do understand the dynamics and the importance of fi xing the issue. Hopefully we’ll get there. The steps have been small and moving slowly, but I’m relatively optimistic that we’ll get there, hopefully in the near future, as far as improved transition from site of care from hospital-based to community-based systems.

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