Progress in Value-Based Reimbursement

J Clin Pathways. 2021;7(5):13.

Oncology drug spend is expected to increase to nearly $230 billion by 2023. One key driver of this increase is immuno-oncology drugs, which are costly but also have significantly improved the outlook of indicated diseases. Articles in this issue include research on new payment models and payer management tools that are starting to emerge in an effort to more effectively manage costs. In addition, results from a retrospective real-world study of the effectiveness of eribulin in subgroups of metastatic breast cancer (MBC) patients with poor prognostic characteristics is presented. We close this month’s issue with insights on the 2021 Oncology Care Model (OCM) evaluation report released by the Centers for Medicare & Medicaid Services (CMS) in January 2021. 

In a study conducted in 2017 and published in 2019, Runyan et al noted that the price of oncology drugs in the United States was continually increasing and explored whether changes in cost management were being implemented. The study found that payers were still primarily using traditional management tools in oncology, which appeared to be relatively ineffective at managing cost. Providers are also seeking new tools to evaluate clinical and cost-effectiveness of treatments, as they are experiencing increased financial pressures from value-based care arrangements. This issue’s study focuses on changes in payer management tools being utilized today and how payer management is influencing physician prescribing, aiming to understand whether the US system is moving toward a value-based approach to oncology care management.

On the clinical side, Sarah S Mougalian, MD, and colleagues present a real-world retrospective analysis on the use of eribulin utilization and outcomes in a subgroup of MBC patients with poor prognostic characteristics. The importance of this research is that we have seen advances in therapy that have improved survival rates, but these improvements have not been observed equally across all age groups and races; the presence of comorbidities, poor functional status, and undertreatment are associated with worse outcomes among older patients. Authors were able to demonstrate the clinical effectiveness of eribulin in these subgroups of MBC patients, when used in accordance with the approved US indication. 

Finally, in January 2021, CMS announced another OCM evaluation report reviewing activities and results for performance periods 1 through 5 of the pilot. Previous installments in the Pharma Insights column series provided insights on prior OCM reports. In this issue, Maureen Hennessey, PhD, CPCC, CPHQ, and Elizabeth Oyekan, PharmD, FCSHP, CPHQ, add their observations on the most recent report, focusing on Medicare spending as well as other performance measures related to the patient experience, management of depression and pain, emergency department and hospital use, end-of-life care, and medication utilization and selection. Insights gained from this performance evaluation have potential applicability to the transformation of oncology as well as other specialty practices and primary care.