Change on the Horizon for the Management of Oncology

Oncology care is undergoing seismic change, driven largely by three factors: value-based care, precision medicine, and digital health. “The ground is shifting right under our feet,” said Therese Mulvey, MD, the director of quality safety and value at Massachusetts General Hospital, during a presentation at AMCP Annual Meeting 2018 on developments in oncology management.

The overarching issues in oncology right now are the cost of cancer drugs, the uninsured population, heath disparities, and care delivery systems. “We cannot be blind to the cost of cancer drugs anymore,” said Dr. Mulvey.

Precision oncology is a costly area of care. These therapies require next-generation sequencing to match patients to the appropriate agent, and treatments will add to the daily management workflow, said Dr. Mulvey. “We cannot just send these patients to the emergency room to manage toxicities [associated with these therapies].” Precision oncology involves targeting a smaller and highly selected group of patients. “These therapies require patient engagement,” she said, as these agents have certain toxicities for which patients need to be aware and mindful.

New oncology payment models should focus on delivering patient-centered care. Payment models drive care delivery, and costs influence outcomes and value. Pathways are a tool to influence outcomes, safety, and cost.

She gave an example of the Centers for Medicare & Medicaid Services’ Oncology Care Model (OCM), which focuses on care coordination and enhanced services to beneficiaries. The program targets high-volume cancers, including breast, prostate, lung, colorectal, lymphoma, leukemia, ovarian, or pancreatic cancers. It involves a two-part payment methodology: A $160 per-beneficiary, per-month care management fee plus performance-based payments. The care management fee is provided to develop the infrastructure to develop practice requirements, metric gathering, and quality and performance improvement. OCM involves the following six practice requirements:

  • Patient access 24/7 to clinician who a has real-time access to the practice’s medical records
  • Attestation and use of Office of the National Coordinator for Health Information Technology-certified electronic medical records
  • Utilize data for Continuous Quality Improvement
  • Provide core functions of patient navigation
  • Document care plan in accordance with the Institute of Medicine
  • Chemotherapy treatment consistent with nationally recognized clinical guidelines

High-quality care involves clinical quality, is patient-centered, and is affordable, and this should extend to both the patient and payer, she said. While overall survival is the “gold standard,” and progression-free and event-free survival are important for drug approval, patients care about quality of life, she said, noting the importance of patient-reported outcome measures.

Dr. Mulvey discussed a study published by Basch in the New England Journal of Medicine in 2017 that found patients who self-reported actually had a median survival that was five months longer compared with those who did not (31.2 vs 26.0 months; P=0.03). “When did we stop listening to patients?” asked Dr. Mulvey. “I think this is the biggest travesty in healthcare.”

In 2015, global costs of oncology therapeutics and supportive care medicines increased by 11.5% to $107 billion. Oncology drug prices are rising faster than any other drug space, she said, and patients are bearing more of the cost. Dr. Mulvey noted that patients want to talk to their doctors about medication costs. “When I went into oncology, there were no financial counselors,” she said, “but now it’s part of what we do every day. It is important to ask patients what really matters to them.”

She concluded by discussing digital health, which can be used to improve care and interact with patients and populations to provide high-quality care. Specialists have not picked this up in the way primary care providers have, Dr. Mulvey said. “The path forward is complicated and requires new metrics and care delivery models,” she added.

“The way we practice medicine today will look nothing like the medicine practiced in the future,” Dr. Mulvey concluded.

Presentation B1: Key Forces Driving Change in Oncology. AMCP Annual Meeting 2018.