Advancing Value-Based Oncology With the Predictable Cost of Care Working Group: Part 1

In this interview, experts Gordon Kuntz and Carole Tremonti, RN, MBA, discuss the goals, challenges, and collaborative efforts of the Predictable Cost of Care Working Group, highlighting its role in developing a standardized model for predictable oncology treatment costs to support pathway developers, payers, and value-based care stakeholders.

Read the transcript:

Gordon Kuntz: Welcome to Oncology Innovations, a Journal of Clinical Pathways podcast, focusing on candid discussions with innovators dedicated to enhancing quality, value, and the role of clinical pathways in the evolving cancer care ecosystem. I'm your host, Gordon Kuntz. I'm a consultant with 20 years of experience in oncology clinical pathways and the business of oncology.

I've worked with oncology practices, pharma, payers, group purchasing organizations (GPOs), and pathway developers—basically, every aspect of the oncology ecosystem. I'm really looking forward to today's conversation.

We're joined today by Carole Tremonti, senior director of customer success and provider partnerships at ConcertAI. While this is a new role for Carole, it is not a surprising move by any means. Carole is a pathways expert and longtime innovator in oncology care. I've had the pleasure of working with Carole for several years, and over the past couple of years, collaborated with her on several projects. Today, we're going to be talking about the Predictable Cost of Care Working Group that she and I comoderated in 2024. Welcome, Carole.

Carole Tremonti, RN, MBA: Hi, it's a pleasure to be here.

Kuntz: Let's jump into our topic. Can you describe the goals of the Predictable Cost of Care Working Group for our audience?

Tremonti: Yes, I'd be happy to. We had 4 goals at the outset. The first was to bring together a diverse, multidisciplinary group of relevant stakeholders who are decision-makers for the inclusion of treatment, meaning what is decided to be a preferred treatment on pathways.

The second was to create a model to define the predictable cost of care, not the total cost of care, for any given oncology treatment. We chose predictable cost of care because we could count on what those payments would be, and it wasn't a variation. Total cost of care is a retrospective view, and we wanted to be looking at the present.

The third was to establish consensus on the variables that were going to be included in the model. The final goal was to publish our findings so that we could share this information with other members of the pathway community.

Kuntz: We had a great group of cocollaborators for the first phase. When I first reached out, I was so pleased that the major pathway developers, as well as 2 pharma sponsors, decided to join us. How important was it, do you think, to have a group of collaborators like that?

Tremonti: It was critically important. I mentioned previously that we wanted to bring a multidisciplinary group together, and by multidisciplinary, I meant people who touched the space—everyone who touched the space. Treatment selection in oncology is very simple, yet at the same time, a highly complex process as the stakeholders and the stakeholders we wanted to include are coming at the treatment decision from very different perspectives—academic medical centers and those in value-based care arrangements, as well as the payers who are covering the agents and the pharmaceutical companies who would like to be able to provide additional information beyond the clinical trial about their respective products. It was really important that we had reputable representation from each of those domains.

It was the charge of the academic medical centers, the value-based care representatives, and payers to help make the decisions for the group. As you know, we were not quite sure how the group would work together, as these are perspectives and individuals that rarely, if ever, sit down in the same forum to discuss treatment decisions.

What was really wonderful was how fantastically collaborative, curious, transparent, and engaging the group was. It's a problem that they all want to solve, and they recognize that they needed to work together to solve it. They couldn't solve it as individuals.

Kuntz: One of the most striking things was when I did reach out, 2 of the groups that I reached out to said that they actually had been approached by pharma to do separate initiatives but recognized that this needed to be an industry solution. That's been my hope all along through this—that we can develop an industry solution, meaning it's not something that pharma company A produces in a certain way and pharma company B produces in their own way and we leave it up to the pathway developers or the payers or the value-based care intermediaries to figure out how to reconcile those two. That's the situation we have today, but that we can all agree one—what are the standards for developing these models? How are they going to be used? What's included? What's not included? How do we arrive at the costing side of it?

It's one thing to say, "Okay, we have a certain number of units, of hospital days, or drugs, or whatever." But another thing to say, "We understand the cost basis when we actually look at the predictable cost of care."

Talk about how we discuss the costing side because one of the conversations I had early on was that we don't want to get into any particular contracting, and I completely agree with that, but let's talk about that for just a moment, if you don't mind.

Tremonti: The costing side was the most complicated part because how do you come up with a cost that's generic enough to be relevant to all the stakeholders? That was really difficult. It wasn't just difficult establishing what the cost would be—and we ended up using Medicare reimbursement costs because that was universal—but really what got included in the cost.

This is where we had to [make a] distinction. We started thinking about total cost of care, but then we had to make a distinction between what was predictable vs the total cost of care, because we're not just talking about established regimens. We're also talking about evaluating something new that's never been in the market.

It's not always an apples-to-apples comparison. It isn't always new recommended regimen versus tried and true. In that instance, it becomes a little bit simpler to evaluate because you look at all of the predictable costs. What is the treatment cost? Are there hospitalizations, symptom management support, premedications that are required? Is this an agent that's going to require hospitalization?

We got the group to—and this was not easy—hone in on what is something that we can count on where there's no variable. It's not something that might be relevant in one agent or one disease, but not relevant in another. Even though our initial model was focused on one very specific indication, the idea is that this scales across. That is the biggest challenge of the group because, again, they're coming at it from different perspectives. An academic medical center or even a clinical path is really speaking very broadly for entire groups, communities, and providers of oncology care.

Kuntz: Sometimes thousands of oncologists at a time.

Tremonti: Exactly. They're creating content, but some of those are all at risk in a value-based care arrangement. The way they're approaching a decision is distinct from the way a pathway developer may be approaching a decision. When you think about that and that perspective, cost is really important because they're also looking at it differently.

In that respect, we did have to come up with a compromise of what is tried and true and known and what could be used as equal standing for all pharmaceutical companies. In that, we chose not only to focus on the predictable cost but also to use the clinical trial as the framework for what was predictable relative to treatment. You can't use nuanced anecdotal information. You have to use what is universally known.

Kuntz: One of the challenges of putting this together was the original intent was to essentially be able to describe, as I've referred to it, the incremental cost for the drug, but for a newly introduced drug where we don't yet have real-world data.

We might objectively say that's better in some way. It's more complicated, for sure. But when there's a drug just being introduced, it's just been approved, you're trying to get pathways approval, and the pathway developers are trying to assimilate this information and figure out what the impact is going to be for the practices that we're providing these recommendations for. We had to have something that we could all turn to, that we could review objectively and independently, and say, "I understand where that data is coming from." Honestly, the clinical trial, flawed as it may be for this, is really the best that we have to work with.

Tremonti: I agree with that. I don't know that I would say that it's flawed per se, but one thing that was critical to the group was establishing trust and knowing that if the information was presented for a decision-making component, where did it come from, and really being able to track back to a source of truth. The clinical trial is published. That is the most transparent component. That was a way in which we could have an appropriate level of comfort for all those stakeholders. We had to somehow come up with a level, even playing ground, no matter where you're coming from.

Kuntz: One of the interesting things that came out of the conversation was, again, the first goal of this was to be able to deliver better information to pathway developers from pharma companies. Pharma companies can describe the economic value of their drug in a more nuanced way, and pathway developers have more information on which to base their decision. However, as the conversation went on, there were multiple different viewpoints that popped up, all of which I think were valuable.

Talk a little bit about the different stakeholders that were identified during the process who I think will be able to take advantage of this work as well.

Tremonti: We realized along the way that we needed more and different voices, but also, the business of oncology changes very quickly. This group was engaged over a year, and even perspectives over the timeline of a year changed as cancer care was evolving in and of itself. The stakeholders brought a broad organizational view to the dialogue and pushed each other in very different ways about what would work and what wouldn't work.

Particularly useful were those in value-based care arrangements because their goal is so different. It's not so different, but it is unique to, again, the pathway developers. How you could come up with a common ground for them was really challenging. Even more so, the pharmaceutical companies who were not decision-makers; they were listening, they were providing additional information, but they weren't the ultimate decision-makers. The providers and pathway content developers were, yet the pathway developers had to listen. They had to hear their perspective because it's ultimately the pharmaceutical companies who will be coming to the table with this information. It's also important for them that the pathway developers understand their different perspective on the situation.

Kuntz: I think the group did a great job of balancing what's possible from the pharma company's perspective. What can we provide you? What's available to provide you? As well as what do we want from the pathway developer? They found a nice middle ground. I'm very excited to see how this gets used in the future by payers and practices who are entering into value-based arrangements, by those intermediate intermediaries who are promoting and supporting value-based arrangements, and honestly by employers as well, as they're considering which drugs to support and how to put together their own cancer benefits. I think there are a lot of different uses for this in the future.

Tremonti: I agree. We learned a lot in year 1, and I would say the most important thing everyone learned was the importance of listening and then subsequently compromising to get the work done. All of us had to get humble and listen to each other's perspective and then see the problem from a new point of view. It's not easy to put yourself in someone else's shoes. But we did it and we did it because we constantly brought the group back to what our goals were. In a project like this, as we experienced, it's really easy to have scope creep. Scope creep is often a really good thing. They are things that we want to do, but you still have to get the work done.

We had to be very intentional of this, with a constant reminder of what our objectives were, and then also support to say, "Okay, what is a method that's going to work for everyone?" We got there; we got to a place of consensus.

Kuntz: Any other lessons learned from our 2024 experience?

Tremonti: We also learned that we need more people. We needed more perspectives. We needed broader groups of people in the business side of oncology so that we weren't just thinking about the state of affairs today but also what's coming—how our policy changes are different, where we see the business going to bring those concepts into the framework of our thinking. That was important for us.

Kuntz: That wraps up this episode of Oncology Innovations. Carole, thank you for a great conversation, and thank you for joining us today. Thank you to the Journal of Clinical Pathways for producing this episode. As always, our goal is to bring you candid conversations with industry leaders who are driving innovation and shaping the future of oncology care.

If you enjoyed this discussion, be sure to subscribe, leave a review, and share this episode with your colleagues. For more insights on oncology clinical pathways, value-based care, and payer dynamics, visit the Journal of Clinical Pathways and follow Oncology Innovations for future episodes.

I'm Gordon Kuntz, and thank you for listening. Until next time, stay informed, stay engaged, and keep driving innovation in oncology care. Please download, rate, review, and subscribe to the podcast. For more episodes, you can visit www.journalofclinicalpathways.com. Also, be sure to share Oncology Innovations with a friend or colleague.

Join us for part 2 of the conversation coming soon. See you next time.