ACCC 2018: Addressing the Problems Caused by Innovation in Medicine

Anand Shah, MD, MPH

The subject of who will establish quality standards in the new value landscape is a sensitive one for oncologists, many of whom are watching CMS’s experiment with the Merit-based Incentive Payment System and the Oncology Care Model very closely to see how they fare and what the impact will be on practices.

Anand Shah, MD, MPH, chief medical officer of the Center for Medicare & Medicaid Innovation (CMMI), the innovation arm ofCMS, sought to reassure attendees during a panel session at the 44th Annual Meeting and Cancer Center Business Summit of the Association of Community Cancer Centers (ACCC), which is underway this week in Washington, DC. Quality of care, Shah said, will be defined by external stakeholders, meaning that CMMI will not take a unilateral approach to imposing standards in the post fee-for-service world.

He said CMMI is very open to input from multiple stakeholders and encouraged members of the ACCC community to continue sharing their ideas. “We have an opportunity to work together and work on [quality] measures not thought about in the past,” he said.

Barbara McAneny, MD

Nevertheless, it is important to realize that, where CMMI is concerned, “beneficiaries come first,” he said. The drive to improve outcomes and get more value per dollar spent on healthcare is all about the patient.

The panel also included Roy A. Beveridge, MD, chief medical officer of the payer Humana; Barbara McAneny, MD, president-elect of the American Medical Association and chair of the National Cancer Care Alliance; and Gregory Simon, JD, who has served in leadership roles in the White House Cancer Moonshot Task Force. Harlan Levine, MD, of City of Hope in Duarte, California, moderated the panel.

When it comes to worries about satisfying yet-unwritten standards on quality, it’s helpful to keep a simple formula in mind: use of the right drug, in the right dosage, at the right time, said McAneny, who also is known for her pioneer work with the COME HOME community oncology medical home model. “Ask yourselves if you’re complaint with this.” Additionally, oncology practitioners should keep in mind the importance of good customer service. These 2 rules would help to find the sweet spot of the value goal, she said. Beveridge stressed the need for transparent data reporting. Patient outcomes and other data need to be shared across electronic health record (EHR) platforms and institutions to make it possible to understand what is working and what is not. Claims-based data may not be deep enough, and EHRs must be accessible and interoperable to allow the true picture on quality to emerge, otherwise, “we’re handcuffed” in the struggle to improve, he said.

Roy A. Beveridge, MD

Moving from fee-for-service to value-based care can be accomplished through standardization of data across interoperable platforms and institutions and by studying the flow of information, Beveridge said. He stressed that payers are able and willing to play a supporting role in this initiative. Such a collaborative transformation is happening in other medical specialties, but not in oncology, he said.

The concept of transparency in data has another prong, and that is ensuring a “level-playing field for patients,” Shah said. Patients should be able to get the medical information they want, and if they do, this will translate into a competitive advantage for oncologists who, under the CMS reform effort, deliver the best care.

Clarity should also be injected into the flow of money for oncology costs, McAneny said. She noted that the United States typically spends more per capita on healthcare than some other countries that deliver equally good results. The answer lies partly in unraveling many of the mergers and acquisitions that have occurred among cancer treatment centers. Large systems stifle innovation, she said. On this theme, the panel noted that large institutions may be able to offer specialties, such as proton therapy, but they could learn from independent cancer centers that operate on leaner budgets and still manage to deliver good quality care.

Rapid advancements in cancer treatments are also an issue that affects quality of care and value, the panel said. These call for measures of quality that keep pace with treatment advances, but also new methods of managing the sudden economic changes that can take stakeholders by surprise, the panel said.

“The health system is not set up financially to deal with unexpected costs and unexpected benefits,” Simon said. Comparing oncology with commodities trades, farmers and oil merchants can hedge against boom and bust periods, he said. But, if a blockbuster treatment suddenly emerges, and it costs a huge amount upfront rather than a larger amount stretched over many years, because the new treatment actually cures patients, the steep, early cost could play havoc with a payer’s budget.

By the same token, a pharma company accustomed to selling maintenance therapy over a long period could suddenly lose that stream of income. “You look at that scenario and you wonder why prices are so high, and you wonder why premiums keep going up, and the answer is, neither the drug companies nor the insurance companies have anywhere to hedge liabilities to take advantage of the benefits [of new medicine],” Simon commented. “This is a fixable problem. Farmers know how to fix this but pharma doesn’t.”