Is value dead? I was asked this question several times at ASCO 2017 based on the lower number of targeted “value” sessions and smaller turnout.
No. Value has just become part of the vernacular versus a headline topic. The value discussion today incorporates patient-physician shared decision-making, payment models, policy changes, and prescribing decisions, not just pricing. Sessions and discussions at 2017 ASCO reflected this. Here are my top five “Value” lessons from Chicago:
Shared decision-making — still a work in progress
Support of patient and physician dialogue, and shared decision-making are core goals of oncology value frameworks. Presentations on value frameworks highlighted a consistent set of challenges to reach this goal – definitions of value differ widely, and value frameworks as they stand today are not readily translated to the individual patient level nor easily interpreted by physicians. For example, one presenter outlined learnings from other therapeutic areas on the development of shared decision-making tools, with the conclusion that the ASCO Value Framework will need significant adjustments. Another presenter noted that physicians rarely initiate the conversation on out of pocket cost with patients. In addition, a presentation detailed significant gaps that exist in physician understanding of the NCCN Evidence Block’s affordability measure. So where does this leave physicians and patients? With a recognition of a challenge but limited tools to address it. Oncology framework developers recognize these hurdles but limited changes to actual measures are being proposed. However, new value framework approaches, such as the Faster Cures Patient Perspective, are being developed to meet this need.
Which measures are relevant for patients? How can we ensure discussions focus on “patient-defined value”? What are the appropriate tools and frameworks to support shared decision-making?
“Administrative toxicity” — coming to a practice near you
The Quality Payment Program Merit-based Incentive Payment System (MIPS) is causing numerous headaches across the country with new rules and expectations around reporting. Several presentations outlined program requirements and strategies to support practices. While 2017 is a zero risk year with minimal reporting requirements, expectations increase over time. Out of the 15 oncology quality measures included in the program, all three of the outcome measures revolve around end-of-life care. However, data on end-of-life care is currently limited and for most physicians, difficult to secure. Concerns around “administrative toxicity” and “EMR burnout” pose the core question: are physicians ready?
Who will educate the physicians who did not attend similar sessions? How will physicians interpret these quality measures? What appropriate quality measures should be incorporated in future iterations?
Value meets payment
There are currently 115 physician practices aligned to OCM, or Oncology Care Model (or Organized Chaos Mission as someone termed it) - an episodic payment model targeted at improving quality of care while reducing spend. Presentations focused on early learnings: increasing need for care coordination managers, billing complications, challenges identifying patients and significant data limitations around total cost of patient care. Driven by OCM, practices are increasingly implementing pathway programs and leveraging technology to encourage compliance. One practice noted that tying physician compensation to pathway compliance increased compliance by 5% (78% to 83%) and the introduction of software moved this number to 90%. Practices also struggle with interpreting the claims data as part of OCM and other alternative payment models. The program is still in its early days and the CMMI representative noted that his team was comfortable “building the airplane, while flying it”. Fasten your seatbelts, we will be hitting some turbulence.
What is the strategy around pathways? Going forward, how should physicians read claims, and most importantly, interpret them? What are the estimated patient costs?
More biomarkers, more problems?
The Precision Medicine Value session was oversubscribed with a long line outside the room and a full overflow room. Precision medicine has brought many opportunities and challenges, specifically the Keytruda’s cancer site agnostic biomarker indication. Commercial testing companies are interacting directly with patients, which is valuable for patient engagement but can confuse patients around options. Pathways were also seen a way to ensure appropriate testing. Multi-paneled tests have made patients aware that products targeting their mutations may be approved for other tumors, but not their own.
Should providers prescribe the product if patients ask? Can we develop a system for tracking outcomes by biomarker? How will payers and pathway developers assess cancer site agnostic treatments?
More PROs, please
Patient Reported Outcomes (PROs) are intrinsically linked to value as they have the potential to support discussions on “patient defined value”. PROs can truly help to understand toxicities more than reported adverse events and support the development of management strategies. The plenary session highlighted compelling overall survival benefits in patients in an outpatient chemotherapy center.
How do we move from patient reported to patient relevant? How do we develop the right PROs? How can we leverage PROs to move closer to the patients?
The value landscape continues to expand with new considerations and approaches. ASCO 2017’s “less is more” clinical presentations focused on balancing efficacy versus toxicity as well as treatment sequencing. In addition to patient-physician shared decision-making, the role of frameworks in trial design and regulator decisions highlights an increasing interest in policy engagement. Similarly, a presentation on Europe’s ESMO value framework noted that the Magnitude of Clinical Benefit Scale is used to support access and policy decision making like IQWiG in Germany.
Is the Value debate over? No, but if we are asking this question, it may be.
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