Lalan Wilfong, MD: I’m Dr. Lalan Wilfong, the senior vice president of payer and care transformation for The US Oncology Network.
OBR: What are some recent trends in alternative payment models and value-based care in oncology?
Dr. Wilfong: There are a lot of new trends in value-based care for medical oncology in particular. We really have two different flavors that I see happening right now. Obviously, we have the Enhancing Oncology Model (EOM) and traditional Medicare fee-for-service. And then what we’re seeing a huge shift toward is Medicare Advantage and Medicare Advantage programs looking at alternative payment models for high-quality physicians and practices in that space. On the flip side, on the commercial side, we’re also seeing significant interest in value-based care models, whether that’s centers of excellence, bundled models, or even some capitated arrangements. So we’re seeing some of that on the commercial side as well.
OBR: What have been some successes in this area?
Dr. Wilfong: So as far as success in value-based care models, you really need to think about what is the definition of success. And it can vary between the different programs. For our commercial Medicare Advantage space, it’s understanding how we develop high-quality referral patterns and partnerships with different groups, particularly primary care physician groups. And a lot of that play is around steerage, administrative burden relief, and things like that. On the flip side, on the commercial side, as we think about success in value-based care, how do we ensure continued payment for the services that we provide? And again, some of it relates to becoming a preferred partner, where you can have patients steer to you from other high-cost settings.
OBR: Can you describe your experience with EOM?
Dr. Wilfong: There’ve been many successes and challenges in EOM. In The US Oncology Network, we have 12 practices participating in EOM. So over 70% of our physicians are participating in the model because many of our larger practices are participating. We have a history of value-based care work in the network.
Some of the successes we’ve seen relate back to what we’ve been doing for a while now. We’ve already been doing patient navigation, financial counseling, and some of the other things that EOM requires. And it was good for us just to continue to have an incentive to continue those services for the patients that we serve.
Some of the biggest challenges have been the other things to implement. Social determinants of health is a great example of something that EOM required of us to do. I say that was a challenge. It was a challenge to set that up, to figure out the right screening tool, to get the technology integrated, to educate the staff on how to do this, what it means, and how do we take those patients with needs?
Because as a physician and a clinician, you can’t ask patient a question unless you’re wanting to fix it, right? Because [that’s] what we do. And so how do we take those things that we are asking patients now and link them to resources to provide services for them to help them with those things? [It is a] huge challenge to think through that and get it all set up, but a success as well. We’re doing social determinants of health screening in The US Oncology Network. We have a partnership with Find Help. We’re actually able to take [patients] and link them to community health resources and [are] doing quite a bit of work around that. We’ve taken that challenge. Like I said, it was a significant challenge to set this up, and it’s still a challenge, but [we’re] trying to find success in helping our patients do better with cancer care because we’re addressing those needs.
The other challenge that we haven’t figured out yet is around electronic patient-reported outcomes. We have smatterings of that in the network right now, but we don’t have a consistent defined way to handle that. And that is one of the requirements that Centers for Medicare and Medicaid Services is putting on us. And electronic patient-reported outcomes are important. They’re important for patient care – as they’ve shown over and over again in studies – to help patients live longer and do better with cancer care. But implementing them is a challenge, and we’re trying to figure out the best way to do that, and we’re still working on that at this point.
OBR: What are the keys to being a good financial steward while keeping patients first?
Dr. Wilfong: There is a line between keeping patients first and being a financial steward to the greater society. Many times, that is very much aligned. We have to be cognizant of the financial burden that we place on patients with cancer therapy. As we think about value-based care, there’s value to the patient as well, as we think about drug selections that are more cost-effective for them, and as we think about care management that keeps them out of the hospital, keeps them out of the emergency room, and helps them have a better quality of life as they deal with their cancer journey.
In many respects, value-based care and patient benefit [go] hand in hand. Where it gets tricky is [asking] how to make decisions when you’re in payment models that remove the incentive to use high-cost therapies and where you could potentially be negatively impacted as a practice by using high-cost therapies. But if the high-cost therapy is the right treatment for the patient, we want to give that to the patient. As we design and implement models around value-based care, we have to be cognizant of the fact that there can be a little bit of a push and pull between those two scenarios. [We have to] think about how to design the contract so that we are appropriately giving the right therapies to the patient and never stinting care or not giving care to a patient because it could potentially be financially disadvantageous to us.
OBR: What sort of ethical guardrails should be applied?
Dr. Wilfong: It’s interesting to think through the ethical guardrails around value-based care. And even in traditional fee-for-service, there should be ethical guardrails. One of the challenges with traditional fee-for-service that we always ran into is that sometimes we did too much, right? We did too much testing. Just think about cancer screening, for example. If you do a CT scan on a patient who’s not at high risk for cancer, you’re going to see things that are abnormal and then potentially subject the patient to biopsies and invasive procedures – not to mention the worry about potential cancer – inappropriately. Even in a traditional fee-for-service world, if you do too much, you can have ethical issues because of that.
You flip that into a value-based care arrangement, where you worry about not doing enough for a patient. The biggest challenge we see there is that medicine, at the end of the day, is subjective. Medicine, at the end of the day, [involves] a physician understanding the medicine – understanding the benefits of that medicine and the risks – and a patient who has variable comorbidities and potential outcomes from the treatment that we do. Between a physician and a patient, how do you make the right decision as shared decision-making between that physician and a patient?
One of the things you want to make sure you never do is interfere with that relationship. At the end of the day, the physician and the patient together need to make the right decision for them around the treatment that should be provided. One of our jobs in value-based care is to make sure we enable that decision making in the best way possible.
This transcript has been lightly edited for clarity.
