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[MINI-PODCAST] AMCCBS Live: Precision Medicine Reimbursement

March 4, 2022

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Live from the ACCC 48th Annual Meeting & Cancer Center Business Summit, a veteran of value-based payment models identifies her top three takeaways on the future of precision medicine reimbursement, the biggest opportunities to reduce costs of care, and the "elephant in the room" that providers must address to get on the same page.


Deirdre Saulet, PhD
Expert Partner
Advisory Board Company

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CANCER BUZZ: Welcome back to a special edition of CANCER BUZZ from the ACCC’s 48th Annual Meeting and Cancer Center Business Summit (AMCCBS) held in Washington, DC this week. The theme of this year's meeting is the ‘Convergence of Business Policy and Technology’. One of those topics discussed today is precision medicine, how to get paid for it, and how it works with value-based payment. Dr. Deirdre Saulet is here with us now. She's from the Advisory Board Company. Hi Deirdre.

Deirdre Saulet, PhD: Hello. Good morning. It's so nice to be here.

CANCER BUZZ: Nice to meet you. So what do you do for Advisory Board Company?

Deirdre Saulet, PhD: I'm an Expert Partner, which essentially means I get to go around and talk to a bunch of people about oncology, oncology strategy, finances, operations, what they're thinking about in the future. So I have a pretty good gig. I just get to live and breathe oncology.

CANCER BUZZ: What are you hearing this week from the oncology communities as far as their concerns about being reimbursed for precision medicine?

Deirdre Saulet, PhD: A lot. I do think right over the past few years, especially for immunotherapies, we've seen a lot of advances in terms of proving and demonstrating the benefits, the value that they see still huge concerns, when we think specifically about CAR-T and other new gene therapies that might be coming out on the market really costly. Of course, I think for good reason to be quite honest, health plans and employers hesitant to just say, “Hey, yeah, we're going to reimburse you for this, right. For any patient in any situation.”

So a lot of concerns about this, and I think it brings up this bigger question, which we've been, I've been thinking a lot about, which is ‘value’, right? How do we define ‘value’ at a very high level? We would all probably pull up in our minds. The ‘value’ equals ‘benefit’ over ‘cost’ equation, but then you go two inches deep and you get a bunch of stakeholders in a room and everyone's definition of ‘value’ is different, right?

It might be long-term survival. It might be quality of life. It's going to be efficacy toxicity when it comes to cost over what timeframe, right. Is it over just treatment? Is it one year, two years? How many years out? So I think that’s a really big elephant in the room that as an industry, we really have to start talking about and being open about ‘value’ is in the eye of the beholder. And if we don't come to the table and think about what are we actually looking for, plans and employers are going to be hesitant to reimburse.

Providers are going to have questions about who really is the right patient for this treatments and patients are going to be left—you know, quite honestly, probably holding the bag—which is really unfortunate. I don't have a good answer for probably one of my biggest takeaways as we've been thinking about future of precision medicine reimbursement.

CANCER BUZZ: So you've been studying value-based care the last 10 years. Let's talk about what that has looked like over the years.

Deirdre Saulet, PhD: Yeah. So I tell people, I probably did a very bad job on my first ever research study at Advisory Board because it was on value-based payment and oncology. And I obviously did not crack the code.

So if I think about where we started, and it was a lot of private plans working mainly with private practice, independent oncologists to figure out some way to sustain them. And so we saw different episode-based payments. We saw some playing around with oncology medical homes that had a shared savings component. We saw a couple of cancer specific ACOs. We then saw some hospitals get in the game and try to do diagnosis specific treatment bundles.

Then of course we saw the big dogs—CMS and CMMI—come in with the oncology care model. And I think my three biggest takeaways from what I've seen and studied is that one, well, I'm actually going to go bigger, higher level first off. I think I've got more questions than answers. I'm just going to say that, right. It has been a really hard to piece apart—why some of these events successful, why some practices have failed. Oftentimes we'll talk to people who quote unquote “succeeded” and say, what did you do?

And they will be very honest and say, I have no idea. We have no earthly clue, right? Why we sort of got savings back. But the three big takeaways I'll say is that first off participating in value-based payment reform has been really beneficial to plans and to providers, just for the simple sake of having to share data, right? You actually get better insight into what's going on. What is driving your costs? What are areas for quality improvement? And even though there's a ton of work, I don't want to gloss over that because it's a huge amount of work that goes into that.

That has been a humongous benefit. What that quality and cost data usually shows is sort of my second biggest takeaway, which is the biggest opportunities to drive down costs and to improve, or at least hold quality steady is to number one, reduce unwarranted care variation. And that is going to be for imaging. It's also going to be for drug costs, of course, right—such a hot topic. And so how are practices in particular thinking about clinical pathways and really sort of adhering to guidelines.

The second big opportunity to reduce costs and improve quality is to reduce hospital and emergency department visits, right? So how are we doing a better job managing symptoms proactively, you know, having cancer specific, urgent care, keeping patients at home, it's a huge cost savings. And then the third big one, which I think as a country, we do a terrible job at, and we need to get better is end of life care. We know that spending spikes in the last year of life for pretty much all Americans, especially if you have cancer and we just don't do a great job. Having those discussions early on about goals for care.

What do you the individual patient want? We talk about quality of life. I think we also need to start talking about quality of death, and I'm hopeful that pandemic in some way, shape or form is right, is going to allow us to do a better job talking about these things openly and earlier on.

And then the last big takeaway that I've had from payment reform, as you can tell, I've thought about this a lot. My last big takeaway is really that it is hard to do payment reform in oncology, mostly because the volume of patients needs to be worth all of the effort that health plans and health systems and private practices put into being able to pull off payment reform. Right?

No system has been built to do bundles, to do shared savings, to do ACOs. And so if you're doing that, but you're only getting a few patients enrolled in your breast cancer specific bundle, it just isn't worth the effort. So I think it's being really thoughtful about what is the size of the population and how do we make that meaningfully big enough to be able to pull this off and get some valuable insight from it.

CANCER BUZZ: So we spent a lot of time talking about the challenges to reimbursement. What's the value of being here in this forum, where the community can gather and talk about solutions?

Deirdre Saulet, PhD: I think it comes back to this, addressing the elephants in the room, right? It is people not being hesitant to say, “Hey, health plans when you're putting 5,000 barriers in place for us—when it comes to prior auth denials, all of these things, that's actually impacting the patients, right?”

That is hurting patient care. It's hurting the patient experience. That's really not helping us do our job. And then when, again, you can have folks on the other side of the aisle say, well, “Hey, hold up, wait a minute. We actually need evidence. We need comparative effectiveness research to understand that truly this is the best treatment for this patient.”

So I trust that you are giving them the right care, right? And I'm going to pay you for that care. So I think it is this time for us to like put all our cards on the table and talk openly and in a collaborative way about what needs to be done moving forward so that we can get on the same page and that we can orient ourselves around the patient, which is everyone's ultimate ambition. I think, especially in cancer care, especially at conferences like this.

CANCER BUZZ: Great. Thank you so much, Dr. Saulet. All of this week's content is on the ACCC website at accc-cancer.org/AMCCBS. From all of us here on the CANCER BUZZ team, have a great weekend. I'm Summer Johnson.

CANCER BUZZ is a resource of the Association of Community Cancer Centers.

The views and opinions expressed herein are those of the author(s)/faculty member(s) and do not reflect the official policy or position of their employer(s) or the Association of Community Cancer Centers.