Driving culture change in the pursuit of oncology value

By | July 26, 2020

Five years ago, if you asked oncologists at my practice to name the list price of a given chemotherapy agent, most wouldn’t have known–unless they were executives, maybe. Pharmaceutical reps rarely talk about costs. The EMRs don’t give list prices. And when we input drug orders back then, no cost analyses were offered.

These days, those same oncologists can quote efficacy and cost data chapter and verse for a variety of drugs. They could tell you that zoledronic acid, a widely used drug for preventing fractures when you have cancer in the bone, costs just 3% of denosumab—without sacrificing efficacy. In the past, the decision between such clinically equivalent drugs was often driven by habit. We were never aware of the cost difference to consider it as a variable.

By building a culture of value, we’re able to favor drugs and drug combinations that are equally effective but less costly than the alternatives, and our practice has begun reining in the growth in cancer’s cost. Over a 15-month period, we reduced cancer drug spend by 13.5%, relative to other practices participating in the Oncology Care Model (OCM), the CMS Innovation Center’s value-based program.

What changed? We committed, as a practice, to adopting a set of value-based care pathways that guide us quickly through treatment options informed by the latest clinical research. These pathways prioritize the most effective treatments with the fewest side effects. And when treatments are roughly equivalent in efficacy, these pathways guide us toward the lower-cost options. Moreover, OCM lets us share in the savings when we deliver high-quality treatments at a lower cost, rather than the traditional model in which practices benefit from drug markups on high-priced agents.

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It’s been quite a culture change.

We knew there would be challenges when we embarked on the Oncology Care Model five years ago. Some of the physicians were concerned that this would add layers of bureaucracy to already complicated workflows, without much benefit. But we were looking five to 10 years ahead, and we knew payment models were going to change. We wanted to be on the front lines of this transition.

Initially, some of our physicians saw the addition of care pathways to our OCM approach as another hurdle, or even a threat to clinical autonomy. But we assured them that we were not looking to be 100% on pathway. We just want to be greater than 80%. They still have complete autonomy. We understand there are cases where the pathway isn’t the most appropriate course. If you’re only 50% to 60% on pathway, that’s when we’d be concerned that you’re deviating from the pursuit of value.

Since we implemented this, we increased pathway adherence by about 15%, and most physicians are 80% on the pathway or better.

We knew we would have difficulty moving the needle by simply pointing our oncologists to a pathway tool. We needed to engage them and appeal to their concern for their patients, their professionalism, and even the competitiveness that propelled them to their careers. One of the main mechanisms we use to achieve that is a practice meeting every two weeks, where our oncologists meet with our colleagues at New Century Health (NCH), whose clinical pathways point us to high-value regimens that prioritize the utmost clinical quality before cost. We didn’t want it to feel like an added burden, so we canceled other physician meetings to make room in the schedule to review our performance and discuss prescribing decisions.

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Typically, we go over the cases of patients whose drug regimens didn’t follow value-based pathways. Often, there are good reasons for one of our doctors to deviate from the pathway. A patient might have a comorbidity that would preclude certain on-pathway chemotherapies. But if a patient’s regimen was off-pathway without a good reason, we do education and go through the evidence about efficacy, side effects, and costs. It’s an open group discussion. Sometimes we go case by case, and sometimes we try to make a theme of it. If six breast cancer patients got a long-acting growth factor and didn’t need it, we might discuss that. We also use these meetings to track other important quality measures.

As a private practice, we can move quickly. With NCH’s guidance, we’ve been early adopters of biosimilars, and we have taken advantage of the price wars that often follow as new options for branded drugs hit the market. We’ve also implemented pharmacy-directed drug changes. Previously, our physicians had complete autonomy over drug regimens. As these biosimilars come out, in some cases, there are three or four new alternatives to the comparable brand-name drug. Keeping all in inventory would lead to wastage. Now, our pharmacists have our physicians’ consent to call the ordering physician and request permission to swap in the preferred biosimilar.

These value-based efforts are doing more for us than just reducing cost trend. We’ve always had a strong culture, but we’ve become more united through this pursuit of value. To know what your partners are doing in open conversation gives you greater confidence in the decisions you’re making. By marrying pathways with regular performance analytics, value-focused meetings, and other support, we’ve fostered a clinical environment in which efficacy and value have become top of mind.

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Mark Walshauser is a hematology-oncology physician.

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