Dr. Mark Walshauser, a medical oncologist and hematologist with Cancer Care Specialists of Illinois, says value-based efforts have spurred culture change in his community practice
High-value oncology pathways are key tools for reducing cancer drug spend, but they're most effective when coupled with tactics to engage physicians and practices. In the May issue of JCO Oncology Practice, experts from Cancer Care Specialists of Illinois (CCSI) and New Century Health (NCH) described how they collaborated to reduce cancer drug spend by 13.5%, relative to other practices participating in the Oncology Care Model (OCM). By marrying pathways with regular performance analytics, value-focused meetings and other support, they have fostered a clinical environment in which efficacy and value have become top of mind.
For perspective on this culture change, we spoke with Dr. Mark Walshauser, an oncologist-hematologist who joined CCSI in 2014.
Q: Was there any hesitation at CCSI about participating in alternate payment programs?
Dr. Walshauser: About five years ago, our practice was deciding whether it wanted to participate in OCM. We knew there would be challenges. Some of the physicians were concerned that this would add layers of bureaucracy to already complicated workflows, without much benefit. But we decided to give it a try. 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.
Q: How did you come to work with New Century Health?
Dr. Walshauser: When OCM first came out in 2016, we contracted with a different vendor to analyze our Medicare data and break it down into interpretable measures—for example, how much we spent in total for a given drug. But the information was still raw. We still needed to manipulate it, and as busy as our practice was, it was hard for our doctors to sift through it all, track our progress and find opportunities to improve.
So, the next year we started looking for a more full-service provider and found NCH. They support us at multiple levels and provide the value-based oncology pathways to guide therapies for almost any case you find in a community practice. They interpret our performance data and give us feedback at the patient and physician level. They join us every two weeks to discuss the data and go through cases. Through these meetings CCSI and NCH have truly integrated.
Q: Were any of the oncologists concerned about losing autonomy due to pathways?
Dr. Walshauser: Initially some of our physicians saw it as another hurdle. 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 about 15%, and most physicians are 80% on pathway or better.
Q: Can you talk more about the meetings between your practice and NCH?
Dr. Walshauser: We have a meeting every two weeks with our oncologists and the NCH team, who joins virtually. We didn't want it to feel like an added burden, so we cancelled other physician meetings to make room in the schedule.
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 co-morbidity that would preclude for 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.
Q: Is there more awareness of the value of different therapies now than in the past?
Dr. Walshauser: Five years ago, if you asked our oncologists to name the list price of a given chemotherapy agent, most wouldn't have known, unless they were executives. Cost is something the pharmaceutical reps rarely talk about. The EMRs don't give list prices. There were no cost analyses when you were putting in orders.
Now, it's much more on our practice's radar. One example: Zoledronic acid and denosumab are two widely used drugs that are equally effective at preventing fractures when you have cancer in the bone. But zoledronic acid costs 3% of denosumab. Five years ago, the docs would have just picked one or the other—whatever they were most comfortable with—but most of them probably weren't aware of the cost difference. In our practice today, all our physicians are very aware of it. We've reinforced the cost and efficacy data many times in our biweekly meetings with NCH.
Q: What impact have you seen on the culture of your practice from this value-based work?
Dr. Walshauser: We've always had a strong culture. I think the value-based approach really makes us a more homogeneous group. To know what your partners are doing in open conversation gives you greater confidence in the decisions you're making.
Read our recent article in JCO Oncology Practice to learn more about how CCSI improved its management of cancer drug spend.