Value-Based Oncology Care: It’s All in the Eye of the Beholder

06/07/18
Winston Wong, PharmD

Value-based oncology care and the role of data integration were key topics discussed at the Genentech Oncology Institute (May 9-10, 2018 ;South San Francisco, CA). The opening keynote session addressed innovations across the care delivery spectrum, ranging from clinical developments to care delivery models and focusing on the movement toward value-based care. However, as with so many other key words in health care today, there is no standard definition of what “value-based oncology care” entails. The only true and honest attempts to define value-based care often begins with “It depends,” which is usually followed by an explanation of how the definition “depends” upon the perspective of the individual stakeholder. The “ah-ha” moment came during a multi-stakeholder panel discussion, which prompted a provider, patient advocate, employer, and payer to provide their views on “value.” 

At the end of the multi-stakeholder panel session, it was clear that while the common goal is to achieve the best clinical benefit, the value proposition associated with the clinical benefit is rather diverse. Providers had the most complex responses—not only is it their desire to achieve a positive clinical benefit, but they also need to monitor and control treatment-related resources, so that the treatment service can be provided within the confines of reimbursement. Under this scenario, a more expensive targeted regimen may provide a greater value proposition, since these regimens are generally at least as effective, if not better clinically, and better tolerated. This scenario would be in contrast to a lower cost regiment, requiring more patient follow-up and monitoring. As alternative payment models shift the cost burden to the practices and provider organizations, the value-based proposition becomes a greater focus. Many contend that provider practices and organizations should see value-based care as an opportunity, and, in doing so, commit to the fact that the practice will need to transform to be successful. This means addressing greater patient engagement, access to care issues, and increasing patient support to navigate through the health care system.

Patient concerns can ultimately be termed as “financial toxicity.” Patients expect to receive a clinical benefit from their treatment option, but the question is whether or not they can afford the treatment. The average targeted treatment course cost ranges from $200,000 to $300,000 and amounts to a 20% co-insurance thus potentially posing a significant barrier to treatment. The starting cost of the new CAR-T regimen is $375,000 to $500,000 for the CAR-T medication alone. This cost does not include all of the ancillary services and treatments that are associated with the CAR-T infusion. The member‘s out-of-pocket costs can be a significant barrier. In short, the value proposition to the patient is the regimen that can provide a positive clinical benefit and is affordable.

For the payer, the idea of value proposition stems from the cost-benefit ratio. The focus of the clinical benefit is the relative incremental increase in benefit over the current standard of care. The cost is simply the cost of the regimen. There is hardly any weighing of the patient experience or whether the regimen being evaluated represents breakthrough technology. The bottom-line proposition for the payer is the increase in clinical benefit and at what cost.

Finally, the employer is ultimately who pays for the care. Payers will often say that they hold the risk for the fully insured business, but it is still the employers—and in some cases, the individual—who pays the premium. Employers want to be sure that their employees are receiving high-quality, affordable health care services. In addition, they are focused on their employees spending minimal time out of work. In other words, the most cost-effective employee is the employee who is working. Employers want to keep their costs affordable and their employees productive.

As evidenced, the definition of “value-based care” is complex and one that will have a different focus based on the stakeholder providing the definition. We may never reach a standard universal definition of value-based care. However, we must realize and accept that each stakeholder brings a different perspective to the table. In order for value-based care models to succeed, we all need to be perceptive of the views of other stakeholders and collaborate to reach the ultimate goal of improving care and outcomes.