At the Community Oncology Alliance’s (COA) 10th National Payer Exchange Summit on Oncology Payment Reform (October 28-29, 2019; Tysons Corner, VA), Terrill Jordan, president and chief executive officer, Regional Cancer Care Associates (RCCA), spoke about his practice’s upcoming transition into two-sided risk in the Centers for Medicare & Medicaid Services (CMS) Oncology Care Model (OCM) as well as cancer care strategy and value-based arrangements across the network.
Journal of Clinical Pathways (JCP) sat down with Mr Jordan to gain further insight into the large community practice’s success within OCM and how value-based arrangements will continue to shape their cancer care operations in the future.
Can you provide a brief background of RCCA? How large is the network, how many patients are treated on an annual basis, and what is the practice’s overall outlook on cancer care?
Mr Jordan: RCCA is a physician’s practice founded in 2012. There were ten practices throughout New Jersey brought together by Dr Andrew Pecora, who had a vision of private oncology practice in the evolving value-based landscape long before the market demanded it. Altogether, there were approximately 67 physicians in the network. In 2013, another three practices consolidated with RCCA, followed by five more practices in 2015. Currently, RCCA has over 120 physicians across New Jersey, Maryland, Connecticut, Pennsylvania, and Washington, DC.
The practice sees approximately 24,000 new patients annually. We have over 940 personnel in our 31 offices, including approximately 240 nurses and nurse practitioners. We are deeply connected to our communities. Our outpatient delivery network is an integrated practice, providing access for our patients and their families in neighborhoods and near their homes. Without our independent physicians and clinical staff, we would not be able to ensure that the patients we serve have access to high quality care at a reasonable cost.
Importantly, RCCA has relationships with all the health systems and hospitals in the communities in which we practice, and we are closely aligned with other nononcologic specialists in our communities, including primary care, surgeons, pulmonologists, and so forth.
At the COA Payer Exchange Summit, you mentioned that RCCA is planning to enter into two-sided risk in OCM PP8. What were the key factors and data that went into this decision?
Mr Jordan: We determined that the market is headed to a place of value, and part of value will ultimately land on providers taking some risk associated with the care they provide. Value aligns the care that is provided with the outcomes that are sought by the patient and their families, so it made sense for us to make this decision.
The second factor that led us to this decision was when we looked at our performance since starting OCM back in July of 2016, we saw progressive improvement in terms of the interventions we were taking. We recognized that we had to carefully navigate our way into value and, more importantly, into risk. As a result, we were quite cautious in ensuring that we had a full understanding of the impact of taking on two-sided risk with regard to our drug dispensing.
We looked at the movement in the market in terms of transitioning to biosimilars. We also looked at the data that we were receiving back from various sources to help us make better decisions in terms of drug choices. There is a lot to be done there, but the market is swiftly moving to patient-centered care—identifying which patients should receive which drugs and how much.
RCCA as a practice believes in value and has made a concerted effort to move in that direction. As a result, we have value-based arrangements with a number of payers beyond OCM, such as Horizon BCBS of NJ, Cigna, Aetna, and United Healthcare.
RCCA initially focused on obtaining OCM performance-based payments by targeting ER, inpatient, end of life/hospice, and site-of-service. Only recently have you begun prioritizing drug costs. Why was this one of the lesser and later priorities?
Mr Jordan: We wanted to make sure that we had a full understanding of the impact of our decision-making on drug choices. Part of it is that you have to have enough data to keep up with and support those kind of decisions. Furthermore, we had to make sure we built a framework or an infrastructure around how to make those types of decisions so that we would understand, or at least have a framework, to evaluate what we thought was the best course of action when it came to drug. These efforts, of course, coincided with preserving high-quality care.
It is important that you have time to digest data and that you have time to put in place the infrastructure to make data-supported decisions that are good for both patients and physicians.
There have been movements in the market that are worth noting. The movement of biosimilars, or the introduction of more and more biosimilars, was a significant change in the market, especially in the evolution from supportive drugs to therapeutic drugs. More opportunity was presented, but again, we had to get ourselves comfortable with biosimilars and comfortable with managing the patient transition to biosimilars when appropriate.
The other vitally important factor to consider was the landscape when OCM was designed. The way OCM was built, you had to look at a number of historic periods prior to entry into the program. When they looked at that data, that data was based on a time prior to the entry of immunotherapies. Immunotherapies ultimately completely changed how oncologists approached many cancers. As a result, it also changed the risk profile and the cost-curve associated with cancer treatment.
Our benchmarks were a bit off, and we found when we went into OCM that the methodologies used to create the risk profiles and cost estimates for our shared-savings participation were actually out of line. It took almost 18 months for CMS to make realignments and the necessary adjustments to begin addressing the fact that immunotherapies had caused a shift in the market and the cost-curve associated with the market, hence another reason why we had to exercise significant caution targeting drug interventions.
What strategies are you using to target drug costs? Are clinical pathways or standardized care part of the RCCA strategy?
Mr Jordan: RCCA follows National Comprehensive Cancer Network (NCCN) guidelines and have followed them prior to OCM participation or participation in other value-based arrangements. We will continue following NCCN, but we have considered whether we will embrace commercial pathways.
We use Via Oncology pathways for one commercial payer program, but we do not use it across the full spectrum of our patient population. When we think about the commercial pathways, we try to frame our thoughts around how they will help us provide better care to our patients while reducing the administrative burden of our physicians. That administrative burden is associated with billing and coding, and the documentation associated with billing and coding that our physicians have to engage in, and the precertification administration. If we determine that commercial pathways would help us limit these burdens, we would be more inclined to consider going in that direction.
In terms of the actual treatment and outcomes for our patients, we are currently looking for more data. While commercial pathways may yield some results, we are looking for real-world evidence at the point of care that can drive physician decision-making. I am not sure if we can call this idea a “pathway,” per se, but that is what we are hoping to find. We have reached out to a number of companies to try to find the technology to do so. Currently, we are working with COTA.
Is there any consideration of developing in-house pathways?
Mr Jordan: Currently, there is not. Our physicians are seeing patients all day long and sometimes into the evening. They are putting in 60- to 80-hour weeks, week-over-week. The clinical staff is already pushed to the brink, and we would have to find additional time to pull together pathways. From there, we would need more time to keep up with maintenance of the pathways, which would be a huge undertaking.
We would prefer to find a solution that allows our physicians to continue to focus on their patients, while being exposed to all of the innovations in therapies, diagnostics, etc. From our perspective, if you are a practicing physician or you have a physician’s practice and you decide to put in place homegrown pathways, and then maintain those pathways, you are likely to be sidetracked from your mission of taking care of patients day-to-day.
As technology advances and we refine the technology associated with diagnosis and treatment, the definition of “pathways” is likely to morph into decision support at the point of care. When we use the word “pathways”
in the near future, we will really be talking about a clinical infrastructure that allows physicians to diagnose and treat patients at the point of care while being informed with the latest, up-to-date, and relevant data that exists in the market.
Are there any other points you would like to make on these topics?
Mr Jordan: I want to stress that all of the decision making at RCCA starts with our clinicians. These are not business decisions, even those decisions concerning drugs. Before these decisions come to the business side, our clinical standards committee (chaired by Dr Dennis Fitzgerald and comprised of our physicians) will review any group of drugs that they are considering. They will analyze the drugs as a group from a clinical perspective with our chief medical officer (Dr Iuliana Shapira), who provides full-time clinical leadership and guidance. After a clinical decision has been made that ensures clinical efficacy, they will transfer it to the business team. From there, we conduct analyses to determine risk from a cost perspective.
RCCA is a physician’s practice. It is 100% owned by physicians. All decisions begin at the top, with clinical decisions being made prior to any business considerations because the mandate of our physicians, our clinical staff, and nonclinical staff is, first and foremost, the well-being of our patients and their families.
