Authors are from The US Oncology Network, a network of independent, physician-owned practices dedicated to delivering value-based, integrated care to patients close to home.
- Stuart Staggs, senior director of Strategic Programs
- Aimee Ginsburg, PharmD, BCPS, director of Pathways and Clinical Content
- Jody Garey, PharmD, director of Clinical Analytics
The rising cost of care remains a deep concern across the healthcare landscape, as costs continue to escalate. CMS’ Office of the Actuary estimates the annual growth in national health spending will average 5.1 percent from 2021 through 2030 and reach nearly $6.8 trillion by 2030.1 These growing expenditures are driven by the increasing costs of caring for patients with chronic or long-term conditions, the aging population and the rising cost of cutting-edge drugs, procedures and technologies.2
Government reimbursement programs and commercial payers are attempting to rein in costs with a variety of value-based programs that rely heavily on the efficient use of data to achieve success. The Oncology Care Model (OCM), CMS’ pilot program for oncology, was one of many value-based programs that leverages data to provide high-quality, cost-efficient coordinated care. Taking a closer look at the ways oncology practices utilized data in the OCM can provide a better understanding for how data can be used in value-based models to bend the cost curve while improving care and outcomes.
Data empowers sound physician decisions
In seeking ways to reduce costs in oncology, it is extremely important to focus on opportunities that enable high-quality and cost-efficient care. A rapidly changing drug landscape and frequent technological advances continue to increase the complexity of cancer care. Oncologists are challenged to keep up with new developments, and the cornerstone of treatment decision-making is to recommend therapies that offer the best patient outcomes, with the lowest risk of toxicity, at the lowest cost. Data-driven tools, such as clinical pathways, support oncologists in the decision-making process.
Clinical pathways are evidence-based detailed protocols for delivering cancer care that enable oncologists to select the most appropriate treatment for patients. Based on disease type, stage, and molecular makeup, as well as patient-specific factors, clinical pathways narrow available treatment options to those that drive the best possible outcome at the lowest cost, providing the most value to patients and payers.
Clinical pathways have become increasingly important in the new value-based environment, where oncologists must balance selecting treatments that provide the best value without compromising on clinical outcomes or toxicities. Across The US Oncology Network (The Network), clinical decision-making platforms, such as Ontada’s Clear Value PlusSM (CVP), present providers with evidence-based options at the point-of-care. Following the data, CVP helps oncologists stay current with emerging treatments and safely integrate them into their practices. Pathways help lower the total cost of care while maintaining efficacy by eliminating the wide variation in potentially costly treatments.3
Data enables cost-reducing drug initiatives
Using data to make decisions for value-based patient care is essential for many cancer care team members. Clinical treatment reviewers and oncology pharmacists managing therapeutic interchange, supportive care protocols, and other drug initiatives require access to patient data to intervene. Identifying an eligible population is critical to maximizing a drug strategy for all patients who may potentially benefit.
One example of such a drug strategy is the emergence of biosimilar compounds to the U.S. market. Biosimilars are therapeutically similar to their innovators yet offer up to a 30 percent discount over innovator biologics in the U.S., with the potential to reduce spending by as much as $100 billion over the next five years.4 Readily available and timely patient data helps pharmacists identify appropriate patients for conversion. Biosimilar utilization plays a major role in value-based care programs by maintaining quality care while reducing costs.
Maximizing biosimilar utilization resulted in The Network having achieved great success in the OCM. To be successful in the program, participating practices were required to meet clinical quality standards while reducing total cost of care. Practices that achieved greater than the targeted savings amount could also receive a percentage of the shared savings as a reward for providing cost-efficient superior care. Over the first five years of the program, The Network participating practices saved Medicare $293 million compared to the benchmark amount and received some of that money back in shared savings. Biosimilar conversion contributed an estimated 27% of the overall savings ($16.1/59M) generated by The US Oncology Network in the most recently reported OCM performance period.
The rapidly changing cancer landscape highlights the need for practices to have access to and use clinical and financial analytics. Since the OCM launched in 2016, costly agents, such as immunotherapies, that are standard of care in many cancers, and biosimilars have offered an opportunity for cost savings. The Network, working with McKesson, created IMPACT Analytics, a clinical analytics team that leverages electronic health record (EHR) data to provide practices access to their treatment patterns, support the development of value-based drug initiatives and identify eligible patient populations. The Network’s Pharmacy Solutions and Practice Transformation teams partner with providers and IMPACT Analytics to implement appropriate drug initiatives such as biosimilar conversion, therapeutic interchange, and dose rounding, as well as optimizing drug utilization during end-of-life care.
There are many decision points and opportunities for maximizing drug selection along the cancer care journey, but it is critical for the care team to have easy access to actionable data to appropriately modify treatment.
Driving better outcomes and costs with OCM data
Before ending in June 2022, the OCM provided practices with comprehensive Medicare claims information, including robust transaction-level insight into the patient experience and total costs. Despite a delay in receipt of OCM data, IMPACT Analytics combines OCM data with that from the EHR to enable practices to evaluate quality efforts around pain, depression, palliative care, hospice, ED visits, hospitalizations and drug usage. By combining OCM and EHR data, root causes of outcomes are easier to identify, and actionable steps to impact the patient journey and cost of care are evident.
Since the OCM was a five-plus year program, trends over time could be examined. Longer pilot programs are helpful in seeing actual results versus commercial models that tend to be shorter, making it difficult to see their impact. Long-term data enables practicesto follow the patient journey from a transformational standpoint, providing perspective on how initiatives and services impact outcomes. Practices can see how they are bending the cost curve, learn more about the real patient experience and understand what is leading to various outcomes—empowering improvements in patient care and costs.
Actionable data will be critical
Value-based care is here to stay, and today’s programs are merely steppingstones to the future. Moving forward, all providers will be part of some type of data-driven, value-based program that will seek to reduce costs while improving quality, technology adoption and the patient experience.
Data is key to transformation. Without it, practices fly blind. Getting access to more information from payers and program administrators in a timely manner when the data is truly representative is critical. Additionally, good systems and teams must be in place to make the information actionable and consumable for practices, providers and even for patients. We are heading in the right direction. The last six years have proven we can successfully utilize data to empower quality care and a superior patient experience while keeping sustainable costs in mind.
1. CMS Office of the Actuary Releases 2021-2030 Projections of National Health Expenditures. Centers for Medicare & Medicaid Services. March 28, 2022. Accessed May 6, 2022. https://www.cms.gov/newsroom/press-releases/cms-office-actuary-releases-2021-2030-projections-national-health-expenditures
2. Why does healthcare cost so much? Blue Cross Blue Shield Association. Accessed May 6, 2022. https://www.bcbs.com/issues-indepth/why-does-healthcare-cost-so-much
3. Wilfong L, Ginsburg A, Hoverman JR, et al. Treatment Pathways for First-Line Metastatic Non-Small Cell Lung Cancer: Cost and Survival. J Clin Pathways. 2020;6(8): 52-57. Accessed May 17, 2022 https://www.hmpgloballearningnetwork.com/site/jcp/article/treatment-pathways-first-line-metastatic-non-small-cell-lung-cancer-cost-and-survival
4. Andrews M. Biosimilar drugs are cheaper than biologics. Are they similar enough to switch? Kaiser Health News. September 23, 2021. Accessed May 7, 2022. https://khn.org/news/article/biologic-biosimilar-remicade-inflectra-drug-prices-patient-choice/#:~:text=In%20a%20survey%20of%20602,brand%20biologic%20to%20a%20biosimilar.
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