Strengthening Pathway-Driven Care Through Payer Collaboration

In this episode of Oncology Innovations, Gordon Kuntz and Dr Lalan Wilfong discuss the evolving role of payers and value-based care intermediaries in oncology, emphasizing the importance of whole-person support, coordinated care, and aligning treatments with patient goals to improve outcomes and reduce total cost of care.

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.

Today we're joined by Lalan Wilfong, MD, senior vice president of value-based care at Thyme Care. Dr Wilfong has been in this role since August 2024, having previously served as senior vice president for payer and care transformation at McKesson. Lalan is a pathways expert and a longtime innovator in oncology care, and I've had the pleasure of working with him on a variety of projects over the last several years. I'm looking forward to our conversation today.

Today we're going to be talking about payers, value-based care in oncology, how practices are adapting to this new world, as well as the Predictable Cost of Care Initiative. Let's jump on in. Welcome, Lalan.

Lalan Wilfong, MD: Thanks, Gordon.

Kuntz: You've been an oncologist for a little over 20 years, and you've worked in the administrative side of oncology, value-based care, etc, for about half that time. Through the oncology medical home and value-based care, it seems that oncology practices have a lot of capabilities to effectively take care of patients throughout their cancer journey.

What do you see as the role for payers in providing this whole-person care? What are they doing right and what needs to improve?

Dr Wilfong: That's a great question. I go back to the beginning of my career, when I started practice and really wanted to provide more robust care for patients, recognizing that a lot of the things that happened to them outside of the clinic we weren't addressing very well. It quickly came up that there is no payment for helping with those things.

Luckily, I worked at Texas Oncology and we had a strong commitment to helping patients with whatever they needed through their cancer journey. It was a commitment from the entire organization that we were going to focus on those things and provide resources, even though the resources weren't typically enough. For example, where I practiced, we didn't have a social worker for probably about 15 years after I started. We didn't have a dedicated social worker for our patient population, which just wasn't reimbursable.

What people have recognized—specifically over the past 10 years—is that time away from the clinic is so critical to patient's outcomes. When a doctor sits in front of the patient and sees them when they're getting the infusions in our clinic, our staff do a really good job taking care of that patient, managing them, and helping them through their cancer. But it's those times away from the clinic, and those things that we don't ever really address, that are the biggest problems. Payers are recognizing that too, and people are finally starting to recognize that if we actually do address those things and spend money addressing those things, the total cost of care goes down. If we're making people better, then we spend less money. It's been a hard concept.

Kuntz: A novel concept.

Dr Wilfong: For years we've fought for payment for navigation—for example, to help us cover those costs. Payment for social work services, which still aren't reimbursed for the most part—and really advocated for payment for those things. Payers didn't trust practices to do that. To be fair, a lot of practices don't have the capabilities to do the navigation the way they should. It's the yin and the yang: they're not getting paid for it, so they can't invest resources in those things; they don't have those resources, so they're not getting paid for it.

Payers started developing their own care models and trying to reach patients and help fill in those gaps as a requisite to people were like, "We have to have something."

It leads to a very disparate system, where you have payers over here doing things to try to help patients, and you have practices over here doing things to try to help patients. There's very little coordination between the two. As an oncologist, I could see all the time that patients were getting called by their payer—who had access to claims but didn't have access to the medical chart or know exactly what I was doing—and would tell patients things that weren't really in line with what I was wanting them to do. To no fault of their own, they were doing the best they could; it's just that they had very limited knowledge of what the actual treatment plan was and how [patients] had actually responded to medications in the past and things like that.

Historically, payers have tried to solve this problem on their own, practices are trying to solve this problem on their own. My hope is that we're finally starting to come to a world where those worlds are aligning, and that payers will recognize that paying practices for services will actually have better outcomes and lower their costs.

Kuntz: Interesting. What's the role for value-based intermediaries? Do we really need another layer? We tend to try and disintermediate things, not re-intermediate things, if that's a word. I understand what you're saying about paying practices, but why do we need these third-party entities, do you think?

Dr Wilfong: That's a great question, Gordon, especially since I work for a third-party entity now. We're very much in a transition phase, where there's still not an alignment of resources, and many practices are trying to build up their navigation teams and do this. It just takes a lot of time, support, and technology—a lot of things that are difficult to quickly turn.

Payers are still reluctant to fully pay practices for the services that they're providing. They see money going out the door, oncology costs are rising, and it's hard to understand that there's a true return on that investment by lowering cost in the long term.

What we do is come in with a novel payment mechanism, where we take risk from the payer and we manage that risk. We take total oncology risk—payment risk for the episode of care that a patient's under treatment for. The payer says, "Okay, I've spent that money. Thyme Care, you go take care of it. If you spend more than that, too bad—it’s your fault. If you spend less than that, you can keep a little bit of it."

Payers are embracing this, and we fully embrace the fact that, like I said, by helping patients get through their cancer journey, we save money. We are able to fund—and have a commitment to fund—a robust care team, technology, and all the things that we believe are needed to support that patient. Most importantly, we try to work very closely with the practice and the oncologists so that care is collaborative and coordinated. That's a huge focus of ours: to really make sure that happens in conjunction with the primary oncologist so that care is uniform and everything is coordinated for that patient. That's the best way that we can do that.

Over time, if practices are ever willing to take risk, which is a big if, then maybe they wouldn't need us anymore. But that's a big if, because it's very hard for practices to put their head out and say, "We are going to take a risk as a practice and a practicing entity in order to fund the initiatives that we want to fund." That's where a third-party intermediary would fit in still at this point.

Kuntz: Tell me a little bit more about the kind of services that you see as essential. I'll break it into a couple of parts in my own head here. There's the medical support. A patient leaves the practice, they've had the infusion. There might be things that happen clinically to them while they're not in the practice that the practice wouldn't normally see, and somebody needs to help them through that. But there are also lots of other things, mental health considerations are real when it comes to cancer, financial issues, nutrition, all sorts of things. Where do you see that support being necessary, and where do you see it being provided or maybe not being provided all that well?

Dr Wilfong: I really think of it—and the way our care team is thinking about it—is in 5 different buckets.

One bucket is acute care reduction. That's managing patients' side effects and symptoms away from the clinic so that they never escalate to a point where they have to go to an emergency room (ER) or hospital.

A simple one is nausea and vomiting. If we stay ahead of that, make sure patients stay fed and hydrated, then they don't have to go to the hospital for nausea, vomiting, or dehydration. But there are a lot of things you can do with infections and other things like that. If you act early, then you can intervene and help prevent patients from having decompensation and needing to end up in the hospital.

Practices try to do that, but most practices say, "Just call me if you have a problem." I know people are working on trying to fix this, but if you call a physician's office, it's going to take a while to get a call back. It may even take a while to leave a message. That's a problem that has to be solved so patients have more immediate access.

Using electronic patient-reported outcomes so patients can self-report has been shown multiple times to markedly improve patient outcomes in this regard. People are much more likely to tap on their phone and submit something electronically than they are to actually pick up the phone and call somebody. So, that's one.

The other is transitions of care. People who are hospitalized, especially with cancer, have a very high risk of readmission and rehospitalization. Can you manage them very closely during a 30- to 60-day period post-discharge to prevent them from getting rehospitalized again? That's addressing whatever needs they had that caused them to be in the hospital in the first place.

Social determinants of health—financials, nutrition, all of those things—helping patients address those things that aren't specifically related to their cancer treatment but obviously affect their outcomes and care. If you can't make it to a clinic, you're not going to be able to get treated. If you're lights go off, you're probably not going to have fresh food because the refrigerator's out. Helping people address those things is critically important.

End-of-life care is another big one. Helping people make transitions to end of life, with cancer care, this is obviously important. The final, like you mentioned, is behavioral health. How do we appropriately screen and help people through this difficult time? That's probably the most challenging one to fix, because there's still a lack of resources around behavioral and mental health that we face. That's something that we need to try to address as well.

Kuntz: It seems like the essence of what you're saying is that there's a role for value-based intermediaries in terms of impacting quality, and maybe you can talk about that a little bit.

At the end of the day, we're all interested in how we help improve patients' lives. Are there examples or some way to quantify that that you could talk about?

Dr Wilfong: That's a great question. The way I look at that is really aligning the treatment and the interventions that we're doing with patient's goals and values.

It's not always about helping patients live the longest—although many times that's what patients want: to live as long and as healthy as possible—but it's really aligning that treatment with what the patient wants.

Spending time understanding and doing a good goals and values assessment with the patient to really understand what the purpose is of why they want to consider treatment, [to] get down into that. If we, as physicians, practices, and oncologists, can make sure that the treatments that we're giving and all of the interventions that we're doing help patients meet their goals and values, that's how we improve quality, in my opinion.

Gordon Kuntz: What do you see for the role for pharma manufacturers? Obviously, they have to own a huge piece of the cost puzzle, but what do you see as the role for them in value-based care, and how can they best interact with practices or these value-based care intermediaries?

Dr Wilfong: Obviously, we can't take care of patients without the drugs that we have. Patients are living a lot longer with cancer than they ever did before because of the drugs and the innovations that we have. Like you said, extremely expensive, but critically important for managing our patients with cancer. With pharmaceutical companies, there are a few different things that are super helpful for them.

One is understanding the value of their drugs. We talk about this a lot with pathways: it's the outcomes that we're getting, the toxicities, and the cost, and digging in and thinking about that. Making sure that we identify the right patient populations for the interventions that we're giving and that we really understand the toxicities for that patient. Because then we can do a much better job at treating the patients who will benefit from the drug and then managing their toxicities well, continuing to focus in on that [is important].

One thing I would really like to see pharmaceutical manufacturers do is digging in on the toxicities more. They report them, we talk about them. What does that actually mean? It's hard to say, but digging in on that more [would help]. I would love to see more publications around that, especially as they go through clinical trials, to help us understand the best ways of managing those toxicities.

There are examples like that, where drugs cause diarrhea and they've said, "Hey, we found in the clinical trial that if we start antidiarrheals empirically, then patients do a lot better." That's super helpful information for us to be able to reduce and limit the side effects of the treatments that we're giving.

And then continuing to focus on education—how do we make sure that patients and physicians understand all the things that we just mentioned so that they can have the full benefit of the drugs that we're giving them? Also, making sure that education is in language that's applicable to our patients' populations.

A classic example I always talk about is drugs that cause a skin rash. Every picture of a skin rash is a white male. In my Hispanic, Black, and other populations, I don't know what that looks like. Give me that information so that when it happens, I can recognize it and then intervene appropriately.

Kuntz: It sounds like there's more work to be done in terms of how to use the drug. The administration is all covered in the package insert, I get that part, but how does it work in practice, and what's the expectation that's going to come along with that? That seems important.

I want to shift a little bit and talk about value-based care itself. One of the trends I'm continuing to watch this year is the shift in practice attitude that's come from value-based care. Practices—and even those who aren't fully immersed in value-based care arrangements—I know your friends at US Oncology are deeply invested in the Enhancing Oncology Model (EOM) and a lot of other programs, but there are other practices that might have a third of their patients in a value-based care arrangement.

They seem to be prioritizing total cost of care over what they historically would've prioritized, which was drug margins, in terms of the economics. They're certainly thinking beyond the rebate or the margin. Is that something you've seen with practices as you've now worked a little bit more outside of the US Oncology bubble?

Dr Wilfong: It's a very interesting time in the world in general, but also in oncology care because unfortunately, drug margins and rebates still drive a lot of the profitability of cancer care. That's how the majority of payment is given still at this point. There's still this conflict ongoing: I get drug margins, I get rebates vs I potentially could give a similarly effective but less costly drug, where I may not have that same revenue coming in.

One of the principles of value-based care is actually paying practices for doing those things that lower the total cost of care and for utilizing drugs more effectively, making sure patients have better outcomes. I still think we're in this big transition phase.

What I do say to your question is: it’s different now than it was a few years ag. Many more practices are wrestling with that concept than I ever saw in the past. Their wrestling with how do we position ourselves as a practice? What is the culture of our practice going to be? How am I going to prepare myself for the future? We're seeing an inflection point now, with all of the pressures on drug margins and all of the stuff going around about rebate transparency and everything. We talk about 340B rebates and transparency. At some point, that transparency is going to turn on us, and we're going to have to be very transparent about how we're getting paid. People are recognizing that this is going to happen at some point in the future. So, how do I position my practice to continue to survive and thrive in the future?

That's what the crux is, because we're seeing a lot in the commercial and government space where people are recognizing that they want to preferentially send patients to practices that are thinking and managing patients under a value-based care model.

We're seeing that in the commercial side with site-of-service differentials. We're seeing that in site-of-service policies, where they're shifting people away from typically hospital-based centers to community [settings]. We're seeing that in government programs, [for example,] they just came out this week talking about more mandatory models. Most of the practices that we talked to are wrestling with this. How do they make that transition into value-based care?

Kuntz: It's interesting. As I talk to my pharmaceutical clients about this, initially there's sometimes a bit of a surprise, and everybody is trying to understand all the concepts. The fact is, it's actually value-based care working like it was intended.

The whole goal was to find the least costly but good-quality alternative. Maintain quality, lower cost. Lo and behold, we have enough choices these days that sometimes that can happen, and practices are acting very rationally in that model to make some of those choices. But it is surprising to those who have had success in the old world. It's an interesting transition.

Speaking of transitions, I have one more question for you before we wrap up today. You've been involved with the Predictable Cost of Care Initiative, and thank you very much, since the very beginning. Could you share a little bit about why you think this is important and how you see the various stakeholders using the output of this process?

Dr Wilfong: We focused for a long time on just the cost of the drugs. We know the drugs are expensive. Cancer care is getting more expensive. Those are things we've talked about for 10 years now, and it's happening today. But we don't really understand how that impacts total cost of care. Can I give a drug that may be costly, but at the end of the day, the total cost of care will be less because that drug drives better outcomes and less toxicity?

We've been a little too narrow-minded in the past about just looking at the cost of the drugs, but really wanting to look at the big picture. Obviously, that's super complicated, because we've spent so much time trying to define what do we mean by total cost of care? When does that start? When does that stop? What do we include? What do we not include? Figuring that out is going to be immensely helpful for us to think about models.

When you talk to payers, some of them get very siloed. The pharmacy team says, "We have to look at drugs and drug costs." The medical, clinical teams say, "Oh, we just have to look at ER admissions and all this." But the innovative payers are thinking about the whole picture. At the end of the day, no matter whether you're a commercial or government programs, as a payer, you're getting a set of money to manage a patient population, and you have to figure out how best to spend that money.

If you spend too much of it, you're either going to lose a lot of money yourself, or employers aren't going to sign up with you again. They're trying to figure out what are the levers to pull to help and manage patient populations better? That will be immensely helpful, and also immensely helpful for organizations like mine, where we are at risk in our contracts. Are there other levers that I'm missing? We know the big ones we just talked about, but are there other things that I'm missing that we could be doing to intervene, to help patients do better, and to reduce waste in the system? There's still significant waste, full spending that's happening.

Are there things outside of drugs and ER visits and things that we should be doing to help patients live better? By looking at the predictable total cost of care and the model that we're creating, we'll be able to understand those levers better.

Kuntz: When I first conceptualized this, it was around pathways. But as we've had conversations, you and I, there are a lot of other potential stakeholders. That's the exciting part, to have this thing that, initially, was conceived for one purpose, be able to be used by practices who are trying to evaluate an estimate. It's not the complete retrospective picture, but it's a reasonable estimate. How is this going to impact my total cost of care models? For those who are developing those models and negotiating, it's something to tag onto as well, as you said, payers and the intermediaries.

Thank you again for joining us on that journey. I always appreciate your input on that.

Dr Wilfong: It's always fun talking to you, Gordon.

Kuntz: We've had enough fun for today. Thank you for your time, but that's going to wrap up this episode of Oncology Innovations. Thanks for a great conversation and thanks for joining us today.

As always, thank you to the Journal of Clinical Pathways for producing this episode. As always, our goal is to bring candid conversations with industry leaders who are driving innovation and shaping the future of oncology care, just like Lalan. 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. See you next time.