Creating Accountability to Patients: A Response to the Roundtable on Value-Based Agreements

Lili Brillstein, MPH, founder and CEO of Brillstein Collaborative Consulting, and nationally recognized thought leader in the advancement of Episodes of Care, offers a commentary on Exploring Value-Based Agreements for Oncology Care in the US, a roundtable discussion produced by Journal of Clinical Pathways at this year’s ASCO Annual Meeting.

The question Omar Ali poses at the start of the discussion is essentially whether there is a place for value-based care and contracting in oncology.

Oncology diagnoses are among the most complicated to bring into value-based care for many reasons. Oncology is not a single diagnosis, and clear identification of like patients requires data from both the payer and provider. Novel drugs and technology are emerging at lightning speed, sometimes with not much mature information about impact to outcomes, and often with significant cost. Furthermore, one diagnosis may have multiple treatment options, and oncology episodes do not typically subscribe to a standard time period. These complications, which make defining an episode difficult, also drive significant variance among treatments, costs, and outcomes for patients with cancer. The criticality of incorporating the concepts of value-based care and the opportunity to optimize care and costs of care for this population cannot be overemphasized.

Variation in care and cost of care often occur among patients with the same clinical diagnosis. This means that while some patients are getting the most optimal care, others may not be, and the cost of that care may be optimized for some but not others, causing potentially devastating effects for patients and the health care system.

The goal of Episodes of Care—the design model most often used for engaging specialists in value-based care—is to study these kinds of variations in an attempt to optimize the care, patient outcomes, and cost of the care delivered. Dr Vaena’s point about there being a lot of different end points in oncology speaks to the need to stratify patient populations into clinically-alike groups so that providers and others can study those variations among patients who would be expected to have the same or similar outcomes, and ultimately make decisions that would standardize and optimize their care.

Dan Wygal’s discussion about needing to be thoughtful about creating meaningful partnerships, and about focusing on outcomes rather than process, also cannot be overstated. The fee-for-service model is focused on pieces of care delivered by individual practitioners, rather than total care provided to an individual patient. Creating functionally collaborative partnerships across that continuum, where various stakeholders work together to build models that focus on and create accountability for patient outcomes rather than on units of care and costs of care, and that allow providers to then focus on reorganizing their processes to achieve those outcomes, allows the shift toward value to begin. 

Dr Hertler raises the importance of determining what “value” means in the context of building a model. This is where bringing all stakeholders to the discussion becomes critically important. Understanding and incorporating the various perspectives around value allows for decisions around end goals and outcomes that takes into account the full view of expectations for a specific population of alike patients. Respectful, collaborative and regular communication among stakeholders is key to success of any value-based model and creates the accountability to the patient that is lacking in fee-for-service.  

Manufacturers have long been interested in figuring out how they become part of the value-based care movement. Astra Zeneca’s partnership with the University of Pittsburgh Medical Center, which ties cardiac outcomes to reimbursement for AstraZeneca’s drug ticagrelor, is a great step in taking real accountability for drug performance and impact on patient outcomes.

Oncology is complicated, and there is a lot of variation in both care delivery and the cost to deliver that care. Accountability to patients is key, and value-based models will help connect health care providers (traditional and non-traditional) across the health care continuum to create that accountability so that patient outcomes and experiences will be optimized as levels of stress and cost are reduced.