CPC & CBEx Keynote Session: How Do We Define Value-Based Oncology Care?

Providing true value-based cancer care starts with defining what “value” is, and that definition differs depending on the stakeholder—patient or payer. Harlan Levine, MD, president, health innovation and policy at City of Hope, opened his keynote session at the Clinical Pathways Congress + Cancer Care Business Exchange 2023 Annual Conference with this sentiment, and it remained an overarching theme throughout his presentation, highlighting the importance of recognizing the need to solve for more than just affordability in oncology care.  

The ”industry view,” Dr Levine said, is that value equals the ratio of quality to cost. For the patient, however, value-based care represents an entirely different view, encompassing survival and speed of treatment, quality of life, respect, and dignity. Dr Levine shared the story of Kommah McDowell, a former patient, whose original cancer diagnosis gave her a less than 5% chance of survival after 2 years, and, if she did survive, she would no longer have the ability to have children. He asked the audience to remember her for the time being as he continued to explore the issues around inequities in health care and access to treatment. 

“Health inequity is profound, and our system exacerbates the problem,” Dr Levine said. That fact that a patient is covered for services under their health plan does not mean they will have adequate access to care. As Dr Levine succinctly put it, “coverage does not equal access.” There is huge variation in outcomes based on zip code, and disparities in care and outcomes based on race: in Black men, the risk of dying from prostate cancer is twice that of White men, and the risk of dying from breast cancer in Black women is nearly 40% higher than in White women. People of color are also diagnosed later and suffer worse outcomes. Additionally, representation in clinical trials is not representative of real-world populations, further compounding the problem. 

The Unique Nature of Cancer Care 

Cancer care is different from other types of care in that it involves rapidly evolving practice patterns combined with low prevalence of illness, high variable costs, and pathways that are evolving year after year, factors that are not present in other diseases. Clinical research and supportive medicine are also uniquely important in cancer care as compared to other types of care. “Let’s not turn oncologists into insurance companies,” Dr Levine said, referring to programs that transfer full financial risk to oncologists, “basically turning them into insurance companies, and asking them to take risk that insurance companies themselves would not underwrite.” 

That’s not to say affordability and waste in the system aren’t problems, Dr Levine continued, or that oncologists, like other physicians, shouldn’t be held accountable for the things they can control, like reducing the number of unnecessary hospitalizations, and giving less effective care. 

“Value-based care needs to account for patient priorities, quality of care, outcomes, and the intelligent use of financial incentives,” Dr Levine explained. “But its definition must also be considered an extremely important and complex issue that’s not unique to cancer, but is more pronounced in cancer.” 

At the heart of the discussion around value-based care is the need to recognize the emotional toll cancer takes on the patient, family, and caregivers. “We must recognize that we can’t ask our cancer patients to go through the cancer journey without getting the psychosocial support that they need,” Dr Levine said. “We need to address that, social determinants of health, and survivorship if we really want to deliver value-based oncology care.” 

Patient-Centered Value-Based Care

The competitive positioning between private community oncologists and academic cancer centers that is all too common in the industry does not make sense from a patient’s point of view, which includes both the desire to get quality care as close to home as possible and the opportunity to get specialized expertise when necessary. In cancer care, the patient should be at the center of a wheel whose spokes include standard therapies, advanced therapies, supportive care services, academic cancer centers, and community oncologists. To best serve the patient and their needs, there must be an open transfer of knowledge between the community oncology practices and academic cancer centers. “The starting point for this discussion starts with the patient’s view of a value-based oncology journey, and our societal obligations for equity.” With this foundation established, only then should the issue of affordability be addressed. 

Dr Levine returned to the story of Kommah McDowell, his former patient with a dire cancer diagnosis. McDowell had to fight to see a surgeon and had to advocate on her own to get to the expertise that was needed for her condition. Through her efforts, the treatment she received allowed her to overcome the initial diagnosis, and she is now married with a child, and is living cancer free. In an ideal value-based care model, Dr Levine explained, a patient would not have to struggle to see a subspecialist—their community oncologist and the subspecialist would work together to treat the patient as a team. 

In closing the session, Dr Levine said, “We need to step back and think about what works, and then we can insert the payment program—as long as we start with the payment program and make incremental changes to the way we do things today, I’m afraid that we will never get to truly patient-centered value-based care.” 

Levine H. How Do We Define Value-Based Oncology Care? Presented at: the 2023 Clinical Pathways Congress + Cancer Care Business Exchange; October 7, 2023; Boston, MA.