The US Oncology Network and Value Pathways in the Evolving Landscape of Cancer Care

The US Oncology Network (The Network) is currently celebrating its 20th anniversary. Founded in 1999, The Network helps independent physicians deliver value-based, integrated care to patients in the community. Through The Network, independent practices can join together to benefit from shared expertise and gain access to resources to advance local cancer care with the aim of delivering better patient outcomes. 

The Network provides practices with access to coordinated resources, best business practices, and the experience, infrastructure, and support of McKesson Corporation. This collaboration allows the providers in The Network to focus on the health of their patients, while The Network focuses on the health of their practices.

Journal of Clinical Pathways (JCP) spoke with three leaders from The Network and McKesson to get their take on the pressing issues in oncology care today and how their structure and clinical pathways are supporting their practice and patient care goals. Marcus Neubauer, MD, is chief medical officer for The Network. He is a founding member and past chair of The US Oncology Network Pathways Task Force and led their collaboration with the National Comprehensive Cancer Network (NCCN) to build a premium set of pathways called Value Pathways powered by NCCN. Diana K Verrilli is senior vice president, Strategy and Practice Solutions at McKesson. She leads the provider specialty business strategy, technology product portfolio, payer contracting, practice transformation, and clinical and pharmacy initiatives. Further, she oversees value-based provider contracts designed to improve oncology care and better manage escalating cancer costs. Heather Morel, PhD, is the chief operating officer for The Network and supports practices with all aspects of operations and strategy implementation. 

Before we discuss the newer Network initiatives, do you want to lay a foundation for those who may not be as familiar with The Network? How did it start initially and who were the key players? Were you founded in response to certain shifts in oncology care?

Dr Neubauer: The Network was formed in 1999 and actually existed in two different precursor groups prior to 1999: American Oncology Resources and Physician Reliance Network. 

To highlight The Network by the numbers: today we have over 1400 physicians and around 500 advanced practice providers. We are located in 25 states and see about 900,000 patients per year. We primarily use a single electronic medical record (EMR), so we have an opportunity to first enter clinical facts at the practices, aggregate data, then analyze, report, and learn from our data at The Network level. This gives you some idea of our scale. We are a multispecialty oncology organization that includes medical oncology, radiation oncology, bone marrow transplantation, surgical oncology, and ancillary support to provide enhanced patient care. 

Our original mission was to provide high-quality care close to home. There were several practices that recognized the opportunity to come together in a beneficial way and form an organization. Practice consolidation made sense 20 years ago and is even more relevant today.

To give you an idea of the challenges back then, reimbursement by Medicare and private payers was not well understood, and competition existed in our communities with hospitals and academic centers. We needed capital to build cancer facilities in order to grow and support our vision for comprehensive cancer care in the community. The Network proved to be a great partner to help accomplish this goal. 

All this being said, I think these challenges pale compared to those that oncologists face today with an onslaught of new science, needs for great technology, data analytics, and new (value-based) government and private payer reimbursement models. Through all these new challenges, I think The Network has become even stronger, and our practices are more aligned with The Network than ever before.

Ms Verrilli: What is happening in the marketplace overall? Several major industry trends are altering the health care landscape: (1) cancer care is increasing in complexity, and across the general health care system, it is more complicated administratively. From a Network perspective, how do we develop processes and tools that enable our physicians to deliver leading edge care to patients—to be pathway adherent, to be aware of changes in protocols, and to stay current on new drugs that come to market? If we think about chimeric antigen receptor T-cell therapy, for example, what is our role in enabling support for this type of therapy? On the administrative side, whether it’s prior authorization, new government requirements, technology, or value-based care–there is more burden on the physician; (2) there’s an increase in health care costs, again, very true in cancer care but really across the board; (3) the government is making major moves—whether it’s proposing the International Pricing Index, the Competitive Acquisition Program, or implementing programs like the Oncology Care Model (OCM)—the government is actively shaping how we’ll be paid and how quality and patient satisfaction will be measured; (4) there are also new entrants, eg, start-up companies that aim to disrupt the market and larger established players like Amazon; and finally, (5) we’ve seen a lot of horizontal consolidation and vertical integration. Some Network practices have been approached to join hospitals and are threatened when hospitals acquire key referring physicians in the market. When Aetna and CVS merged, we had to decide what it meant for The Network? How will this combined
entity impact patient access, patient benefits, narrow networks, etc?  

Finally, another challenge Network practices face is physician burnout. We are investing in programs to address this concern. We believe that cultural alignment and a focus on quality are important drivers that keep physicians and their teams aligned in meaningful ways to ensure the health and sustainability essential to keeping community oncology practices independent.  

Could give us more insight into the Value Pathways that you are currently using, that is, their development and how you update them and work with NCCN?

Dr Neubauer: In the early 2000s, Network practices got together and talked about developing clinical pathways. We had some supporters and some dissenters. But, ultimately, the leaders of The Network (representing their practices) felt this was important for us to do—that is, when there is overlap or duplication among certain therapies, why not identify certain regimens that may
drive better value? That is what we set out to do 15 years ago, and this is still what we do today—identify preferred value-based regimens and present these choices at the point of care. There is a need for providers to have information at their fingertips to make good decisions for their patients. 

Notably, The Network was bought by McKesson in 2010, a very large health care corporation. The Network operates as an independent business organization within McKesson and has been able to retain its general principles, one of which is that clinical pathways are and should be entirely physician led and physician driven.

We have a pathways committee of 13 physicians. We felt this was a good number enabling us to be nimble, especially with the onslaught of new drugs entering the market. Starting in 2013, we include NCCN guideline panel members on our pathways committee. This is unique; we are the only pathways program with this deeper relationship with NCCN, where members of NCCN Guideline Panels are also members of our Pathways Task Force and contribute to the content, decision making, deliberations, and the final vote. Having NCCN panel member participation lends extra expertise and validation. We changed the name of our pathways from “Level I Pathways” to “Value Pathways powered by NCCN” in 2013 to represent this relationship.

The committee meets once a month by phone conference, twice a year in person, and even more often by email as we prepare for our monthly call. We currently have 25 pathways that cover about 95% of the cancers that occur in a community setting. To keep pathways up to date, McKesson supports us with five PharmDs who continually mine the literature to determine what could be pertinent to our pathways and whether it’s practice changing for us to review.

It is a huge undertaking to keep these pathways current. I give credit to the physicians who are on the committee, and I give credit to McKesson for providing the substantial support, both with personnel and with technology, to keep them up-to-date.

You mentioned at the beginning that there are over 2000 physicians and advance practice providers in The Network—are the clinicians across The Network generally receptive to the pathways that are decided on by the committee? Is there a certain level of debate and disagreement?

Dr Neubauer: That is an excellent question. I left out a very important part of our process; I talked briefly about how we review content and how the pathways task force deliberates. To your point, we do not want to be prescriptive. We want to be sure there is an opportunity for the users of our pathways to provide input before any change becomes official. We have an open comment period. Having the NCCN guideline panel members involved certainly helps the strength of our choices and suggestions, but we still have some dispute of our recommendations through the open comment period, and we take this feedback back to the pathways committee.

This process is important to gaining physician buy-in. This is why so many of our providers use pathways at the point of care, because they have been involved in some way in the process. 

Dr Morel: The pathways committee and pathways themselves have provided a very solid backbone and cultural connection system within all our practices. Further, we have integrated our pathways into our EMR and other technology platforms. These tools are in the workflow of each of our medical oncologists. We also have pathways for radiation oncology. As an organization, we’ve doubled down on this, not only ensuring that the pathways are up-to-date, but also that they are easy to access at the point of care for our clinician. The ability to make a decision within the framework of the pathway is critical.

I would like to echo that our partnership with NCCN over the last several years has been critically important, because our pathways should be shared beyond ourselves. They’re disseminated via our technology to other practices outside of  The Network. Practices that use the iKnowMed EHR system have access to NCCN and Value Pathways in their workflow with the use of our technology toolset.

Dr Neubauer: The real advancement we have brought to the practices over the last few years is technology. We have a decision support tool called Clear Value Plus, a web-based tool integrated into our EMR. The beauty of the Clear Value Plus tool is it is presented to the physician at the point of care. With other pathways programs, it’s not uncommon for the pathways to be a documentation tool where information is entered by support staff after treatment has already been selected. With Clear Value Plus, it’s common for our providers to select and enter treatment information in real time.

You will hear from our physicians that they engage with the clinical pathways at the point of care for two reasons. One, it is educational. You can imagine being a community oncologist and it has been 4 months since you’ve seen a patient with, say, advanced pancreatic cancer and you can’t recall all the regimens, what biomarkers to test, if there are any familial risks, what genetic testing should be done, if any, etc. You get all this information in Clear Value Plus.

Second, it documents the treatment that you make. We can closely monitor pathway adherence from practices down to individual providers. One thing that is special about The Network is we can compare one practice’s performance against another and establish benchmarks. We typically hear from the practices that they appreciate this level of data and comparison, so they can learn and improve.

Can you give us an idea of what that technical support, for example, in terms of data analytics, looks like? 

Dr Morel: We do make significant investments to support pathways in our technology. 

Each practice can have slightly different programmatic schemes for how they want their physicians to comply with pathways. Those are decided at a practice by practice level.

Some practices may be so engaged with pathways that they will look to ensure that every regimen is compliant and, if there is a regimen that is ordered that is not supported by pathways, to ensure that it has further internal review by peer physicians within the practice. In this way, they are ensuring that they are protecting against reimbursement hazard, as well as ensuring that regimens given throughout the practice by our shared services pharmacy and infusion team are well understood and that any excursion outside of that has been thoughtfully made. That is just one of the ways that technology can enhance the workflow and care that our practices provide. 

We aggregate our practice pathway regimen data but can also drill down to a prescriber or practice level. Largely, we work to see how practices as a whole are functioning against the pathways and how we, as a Network, are functioning against the pathways.

That is unique and powerful because we can document for payers what percentage of our patients are treated with on-pathway regimens when we are in discussions with them in which we are trying to eliminate unnecessary prior authorizations through the use of our pathway data. In our discussions with payers, we ask them to consider that if a regimen is on pathway, then they should exempt the physician from making the prior authorization.

The other piece that we haven’t really brought into this conversation but is critical is the culture of research within our practices. Many of our practices are strong leaders of community oncology research where they are conducting interventional clinical trials to evaluate the effectiveness of yet to be proven Food and Drug Administration products or indication follow ons for approved products. In addition to that, we have an active group of physicians who use our data to evaluate questions about the health care delivery and health services aspects of community oncology. This group actively studies and publishes best practices from insights that we’re gathering from our own practice data. Those two things help to contribute to the long-term success of our practices as well as our success with payers. We will continue to drive this culture of bringing together the evidence to the point of care where the physician is having that discussion with the patient and making therapy decisions.

Could you expand on how the payers have received the pathways and reacted to the
relationship with NCCN? Can you also comment further on the way payers view the pathway work that you’re doing?

Ms Verrilli: The relationship with NCCN has enhanced the development of our pathways process. The efficiency of our process as well as the integrity of the pathways has played an important role in enabling Network practices to negotiate an exemption from prior authorization requirements and has supported performance measures in many value-based contracts. 

Through the clinical decision support solution, Clear Value Plus, Network practices can demonstrate transparency around adherence to pathways and reveal through detailed reports  physicians’ adherence levels to NCCN Guidelines and Value Pathways; overall, through this capability, we have opportunities to eliminate prior authorization work, reduce the administrative cost, etc.

There are payers that we work with today where the prior authorization requirement has been dropped.

Could you tell us about your experiences with OCM and maybe some of your anecdotal experiences with practices and the progress made?

Dr Neubauer: This is a large topic, but I’m going to try to be brief here. When OCM first was announced in 2015, it was in draft form. There was a request for feedback, so we tried to quickly learn what it was about. After we started to learn more, we realized how significant the OCM could be—it looked like the catalyst for the transition to value-based care, primarily because of its size and scale.

We talked to our practices about it. As Heather said in the beginning, our practices are independent. We provide management and support but, ultimately, it was their decision to make. Over time, almost all our practices (but not all) decided to participate. Most of them felt that the shift to value-based care was real; you can hold out and see if it really happens or you can be part of the transition. A majority of  The Network practices wanted to get involved. It may sound obvious now, but in the beginning, it was not clear this was a feasible model. It could’ve been something that was too risky or complicated. Either way, our practices, for the most part, wanted to participate. 

Once the model started, July 1, 2016, there was certainly a learning curve. There are many expectations and requirements in the model. Our practices quickly started hiring new positions such as navigators and social workers; changed the way they dealt with inflow of patient calls; and even restructured the way the practice functioned. We saw quite a bit of practice transformation early on. Most of our practices have continued to try to meet the demands of the OCM and perform well. It’s not easy. If you look at some of the benchmarks for success in OCM, one of the most notable ones is, “can you achieve a performance-based payment by saving Medicare money?” This is very difficult to do because of the rising cost of cancer care, the new drugs that come to market, and the way the model works.

I can tell you that over half of our providers participating in the OCM as of July 1, 2019 will be in the alternative two-sided risk option for the OCM. This tells me that our Practices do want to be leaders in this transition to value based care. 

Ms Verrilli: I think it’s important to keep in mind that our focus on value-based care goes well beyond OCM. We were early participants in UnitedHealthcare’s Episode of Care Model. We participate in Aetna’s medical oncology program, in Humana’s, and in a host of other value-based contracts; today only 30% of our contracts reflect fee-for-service payment models. Our collective experiences from these initiatives—their approaches, lessons learned, and the importance of pathways—transcends beyond what the Center for Medicare & Medicaid Innovation is doing and has laid the foundation for how we work with payers today and how we contract in the future.

What are some of the projects on the horizon for The Network, eg, as far as value-based care, future payment models, or clinical pathways? 

Dr Morel: One of the things that has been incredibly powerful with our participation in the OCM is the abundance of insights that we’re gaining from the data that The Centers for Medicare & Medicaid Services is now sharing with us about our practices and patients. We have never, until now, had the in depth data available to us to see what is happening to patients as they navigate across other sites of care. It has been insightful for us to use these data sources to develop and test strategies to attempt to reduce costs holistically for oncology patients and reduce the use of high-cost hospitalization and emergency room services.

With the analysis of the complete dataset for all the services that our Medicare patients use in OCM, we have the best dataset I have seen in my career. In the past, there have been many attempts, but we have never seen this kind of in-depth, timely data. It can only get better from here! It’s pretty exciting and powerful: the ways that we’re able to use that data to very quickly learn and then implement new strategies that are having huge impacts on patients, and providers, and certainly the overall health care system. I think the future is bright for community oncology in value-based care. 

Ms Verrilli: I would add, in terms of future projects on the horizon, we are very interested in the evolution of alternative payment models, bundled payment rates, and strategies to support two-sided risk. What data are required? How do we better support our physicians in this journey? We’re going to see much more focus on bundled payment rates. Future payment models will require payment for value, comprehensive data analytics and transparency, two-sided risk, enhanced patient satisfaction, and the use of real-world evidence to demonstrate improved outcomes and value. Finally, we will continue to see payers narrow their networks with a focus on preferred or high-performing providers. So, demonstrating that you’re a high-quality, efficient oncology practice will be increasingly more important.  

Dr Neubauer: From my point of view, looking into the future, we need to make sure that our providers are confident and can manage the explosion of new information. This is exciting for patients but also daunting to keep up with all of this. We want to make sure that we are on the forefront of precision medicine, whether it is in clinical research or clinical practice. The amount of information will only grow; it is not going to plateau. We will continue to learn more about what drives cancer. We are committed to making sure that physicians in our Network are kept up-to-date and have access to the tools and information they need to provide the best care for their patients.