Tuesday, Dec 19, 2023

A Different Perspective on Value-Based Oncology

Harlan Levine, M.D.President, Health Innovation and Policy, City of Hope


My colleagues often ask why it has been so challenging to produce a successful value-based care product in oncology. For me, the first question isn’t, “how will we deliver value-based oncology care?” We must begin with, “how will we define value-based oncology care?” It’s difficult to achieve success in value-based care before defining what value is.  

How do we define value? Let’s ask the patient. 

The definition of value differs based on which stakeholder group you represent, but the most pervasive definitions always include the cost of care. To most in the insurance industry, it is about saving money. But if we ask patients to define value, it starts with survival. From there, patients will include returning to the normalcy of their lives, the patient experience, and care that is coordinated and respectful. The speed and ease of access to an effective treatment is also important. To a cancer patient, WAIT is a four-letter word.

This was the case for Kommah, who at age 29 discovered a painful mass in her right breast. For seven months, her primary care doctor reassured her that she was too young to have cancer. A biopsy and full evaluation were finally performed which led to a diagnosis of stage 4, triple negative inflammatory breast cancer. Her oncologist at the time said there was little that could be done, and she should get her affairs in order. But Kommah did not accept this as the end of her journey. She navigated the system and sought a second opinion from City of Hope. I will get back to her story in a bit.

Cancer care is different. 

To understand how to define "value" in oncology, we must recognize that cancer care is different from other chronic illnesses. The approaches that work for other chronic conditions do not work for oncology, which requires unique solutions due to the speed of discovery, drug development, and evolving practices. And unlike other chronic conditions managed in population health programs, the outcomes are not driven by patient behaviors or measured by proxies of impact using metrics like A1cs or blood pressure levels. Successful outcomes result from accurate diagnosis, optimal therapy, leveraging the most cutting-edge science, and management of side effects.

Imagining a more value-based, affordable oncology ecosystem begins with acknowledging that the transformative changes in cancer pose unique challenges in terms of defining the level of sub-specialty expertise needed to constitute an appropriate provider network. Genomics has expanded our understanding of cancer from dozens of conditions to hundreds, many defined by a DNA blueprint. The range, complexity, and importance of diagnostic tests has expanded, and the pace of emerging therapies has never been greater. As a result, the need for sub-specialized knowledge and expertise is increasing. Moreover, there are certain clinical scenarios that require academic center expertise and a few that require it on an emergent, seamless basis. Narrow networks and risk transfer that disincentivizes access do not solve the problem and likely exacerbate it, particularly for traditionally under-represented populations. 

Health inequity is profound, and our system exacerbates the problem. 

An extremely important and complex issue is the huge variability in outcomes based on zip code and disparities in care based on race. For example, African American men are twice as likely to die from prostate cancer and African American women have a 40% higher risk of dying from breast cancer compared to their white counterparts. 

People of color are not only diagnosed later and suffer worse outcomes, they are also underrepresented in clinical trials, which might offer the best treatment option along with providing insights to help many more patients in the future. While African Americans make up about 15% of cancer patients, they only represent 4 - 6% of patients in trials.  

Looking ahead, we need to ask ourselves, “will these gaps improve or worsen as we move populations into narrow networks with restricted access to academic and high-volume centers?” For example, Medicare Advantage has significant representation of minorities and people of lower socioeconomic status, and 60% of Medicare Advantage plans do not include any of the 56 NCI-designated comprehensive cancer centers. For some complex procedures and cancers, such as pancreatic cancer surgery, Medicare Advantage beneficiaries have significantly higher mortality rates, with patients being twice as likely to die within the first month compared to their peers with traditional Medicare.


As a former managed care executive, I understand the inclination to consider community practices as an equivalent, lower-cost alternative to academic medicine. But in cases where the community does not have the necessary capability or the volume to deliver it safely, if we don’t provide access to the appropriate academic cancer center expertise, we are surely not delivering value-based oncology regardless of the short-term dollars that may be saved. If we don’t update health plan network requirements to include such expertise, we will also be perpetuating health disparities and adversely impacting clinical research. Now is the time to stop pitting academia against the community providers and re-imagine the relationship between the two, viewing it more as a fluid, collaborative ecosystem.  

Reimagining the healthcare ecosystem.

I would like to plant a seed for how we might reimagine cancer care delivery as a collaborative ecosystem. Too often, value-based solutions position the community network and the academic medical centers as competitors. But this competitive positioning misses the patient-centric point: most patients want care close to home, while others require specialized services. Rather than pitting these two equally important pillars of the ecosystem against each other, we need to modernize our definition of network adequacy and encourage alignments that establish tight partnerships between the community and academic medical centers so patients can seamlessly receive the care they require at the right place at the right time. 

Future success measures should focus on delivering equitable care, shifting complex care to appropriate levels of expertise and less complex care to lower cost sites, appropriate clinical trial enrollment, appropriate utilization of new and emerging therapies based on clinical needs, and availability of integrated supportive care services. This would move us closer to value-based oncology care and is a stronger foundation for addressing other important opportunities such as value-based contracting for high-cost medications.

The starting point for this discussion is to incorporate how a patient views a value-based cancer journey, how we as a society should prioritize health equity, and then, with this foundation established, work to make it affordable by removing sub-optimal care and payment of intermediaries that do not deliver value.

The future of value-based care. 

Let’s revisit our patient, Kommah. She clearly was a fighter. And I am happy to report that she still is today, but now as an advocate for others.  

Kommah had to fight to see a surgeon, then advocate on her own when she was told nothing could be offered. In an ideal future state, she would be able to easily access a surgeon for a speedy evaluation of her breast disease. And upon diagnosis of a complex, uncommon cancer with limited treatment options, her community oncologist and a breast cancer sub-specialist would manage the case together. Perhaps some complex treatments would be initiated at a Comprehensive Cancer Center, and then she would receive care back with her community oncologist. Payment strategies would need to be developed so each of the stakeholders is fairly treated, and the patient journey map would be built upon the experience we would want for our own loved ones. 

For future patients like Kommah, value can be created when they seamlessly receive the care they need, the physicians work together, and the right treatment is provided at the right time. This can be done, but it starts with defining value-based oncology care by incorporating the patient perspective. Because one day, that patient perspective may represent someone you love. 

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