What the Growth of Medicare Advantage Means for Value-Based Care in Community Oncology

In this interview, David Eagleton, Oncology Care Partners, shares his thoughts on the growth of Medicare Advantage and its impact on community oncology practices in providing value-based care. He participated in a panel discussion titled "The Hunt for Value in Value-Based Cancer Care: How to Meet Stakeholders' Evolving Demands" at the 2023 Clinical Pathways Congress + Cancer Care Business Exchange.

Transcript:

David Eagleton: My name's David Eagleton. I'm a senior vice president with Oncology Care Partners.

What were some of your key takeaways from the session “The Hunt for Value in Value-Based Cancer Care”?

David Eagleton: My main takeaways were that everyone has a little bit of a different take on what value means, and I think that's right. There's not one definition for value in value-based care, and that's what drives some of the issues inside of value-based care is that not everyone knows what it means.

In general, some folks are a little hesitant to be supportive of Medicare Advantage and the penetration that's happening in Medicare Advantage. My takeaway there is that if we are able to partner with the Medicare Advantage organizations and create differentiated relationships, we're able to remove a lot of the roadblocks that many practices are seeing today. Some of my other panelists didn't necessarily see it that way and thought that Medicare Advantage was not necessarily the best thing for oncology moving forward, and that's a fair opinion. But, what it really comes down to is that Medicare Advantage is coming, it's over 50% of the Medicare beneficiary population today, and it's only going to grow from there. So it's something that we're going to have to learn to work with moving forward.

What are some of the benefits of Medicare Advantage?

David Eagleton: I think some of the advantages are expanded benefits for some Medicare Advantage beneficiaries. So things like a golden sneakers or gym membership that's included, transportation to and from your clinic, among other things. There's actually also free, sometimes, caregivers who can come to your home as an additional benefit to Medicare Advantage. So there's many different incentives that are associated with Medicare Advantage. But it's not the best thing for every beneficiary if we're being honest. For example, my grandparents. My grandfather was a colonel in the Air Force, and so they have a TRICARE benefit, which doesn't match up with Medicare Advantage. It just doesn't make sense for them to be on Medicare Advantage.

In the same breath, my great uncle, he loves his Medicare Advantage plan because it's low premium and the max out-of-pocket is actually lower than what you see in traditional Medicare. So there's a lot of benefits to potentially enrolling in Medicare Advantage, especially if you have a disease like cancer.

What does value and value-based care mean to you?

David Eagleton: Value and value-based care is actually pretty black and white for me personally. It is higher quality care and more holistic care and it's saving cost. While you're doing that, when you save cost it benefits everyone in the healthcare ecosystem. It benefits the patient. It benefits the health plan. It benefits taxpayers, which are all of us. And if you are contracted in a way that is differential, you're also able to benefit from that as a clinic. And that's really what I see as driving cost savings. Now, the quality is another thing.

What it allows us to do when we do get upfront payment for services is it allows us to provide more holistic care to that patient. So when we get a referral, we have a care navigator who reaches out at the outset and starts to prep that patient for their first visit right away, starts to connect them with behavioral health specialists, with palliative care specialists, starting to drive into food as medicine, on down the line in order to be able to really help that patient more holistically. As opposed to just bringing them in and giving them an infusion.

What impact does the growth of Medicare Advantage have on practice leaders and physicians when it comes to risk payments in oncology?

David Eagleton: I touched on this a little bit in my original answer, but Medicare Advantage is coming. Most practices are already above 40% of their volume is associated with Medicare Advantage. That's just the nature of the beast today. As it relates to risk payments, it's something that every practice is going to need to understand how to negotiate with Medicare Advantage plans because the rates that they're providing sometimes are below 100% of Medicare. And when that's happening and you don't have the ability to negotiate that or to really drive that in a different direction, you have two options. One, go out of network with that plan. Or, two, figure out how to contract differentially. That's something that we're doing and we're focused on making sure that we partner with those Medicare Advantage plans in order to drive a differential experience for our patients and also for our own practice team. So that's really where I think that you'll have to look at what risk-based payments look like for Medicare Advantage. You're really going to have to dive in and partner with these organizations moving forward.

Can you share your thoughts on the enhancing oncology model (EOM) from your perspective and/or the Oncology Care Partners perspective?

David Eagleton: EOM is completely aligned with Oncology Care Partners' value prop, trying to lower the cost of care while increasing the quality of care for cancer patients. The reason that Oncology Care Partners did not enroll in EOM was really more of a technicality. We are really trying to grow through risk-bearing primary care groups, most of their Medicare lives in risk bearing primary care groups sit inside ACO reach. You cannot have a Medicare beneficiary sit inside two different risk models. And so, we couldn't actually see many of the patients under EOM with our partners already having those patients in ACO reach.

So, while it is completely aligned and we would've joined, it didn't make sense for us to do it. Now, could we have done it for the handful of patients that maybe weren't in ACO reach? Yeah, we could have. But, the administrative burden of implementing EOM was more than actually worth it when it came down to just those handful of patients.

Is there anything else that you’d like to add?

David Eagleton: I think this is a point that's super interesting. We talked a little bit during this interview about Medicare Advantage, its penetration, its growth in Medicare in general. We're at 60 million Medicare beneficiaries today. In the next 7 years, we're going to grow to 90 million. That's the projection right now of the CBO. That means that while we're already leaning toward practices being majority Medicare, it's going to tip over even further. And so practices are going to need to learn how to work with Medicare and Medicare Advantage. They already do it today, but in a more meaningful way.

I think the more interesting tidbit though, is not what happens at our practices, it's what's happening inside of the hospitals today. When you see what happens with Medicare and Medicare Advantage patients inside hospitals, hospitals don't necessarily like treating those patients because they are not profitable when it comes to that line of business.

So what you're seeing is risk-bearing primary care groups taking a majority of the Medicare advantage lives, and what do they want to do? They want to steer them away from the higher cost settings, the academic medical centers. Don't get me wrong, absolutely necessary to have academic medical centers for high complexity cancers, but not necessary for all cancer types. So what you're going to see here in the future is risk-bearing primary care groups, taking on more Medicare Advantage lives, more Medicare lives, and steering those patients away from the hospital. Creating partnerships with those risk-bearing primary care groups moving forward is the future. And that's what we're focused on at Oncology Care Partners and what we're excited about.