June 22, 2023

Podcast - The Value of Value-Based Cancer Care

Counsel That Cares Podcast

In this episode of “Counsel That Cares,” healthcare attorney Daniel Patten is joined by Ryan Langdale and Mike Brown from Chartis to discuss their report “Unlocking Value in Cancer Care.” They discuss all things value-based care in oncology, focusing primarily on the newest developments in payment models, how digital solutions are advancing value-based oncology care and how providers are adapting to the ever-evolving value-based care landscape. 

Morgan Ribeiro: This is the host of the podcast, Morgan Ribeiro. On today's episode, we are launching our new series on value-based care.

Following the pandemic, many industries have experienced major shifts in the way that they do business, but probably none more than the healthcare industry, which was forced by the pandemic to consider the benefits of value-based healthcare as opposed to more traditional fee-for-service models. This is something we've been talking about in the healthcare industry well before the pandemic ever was even something that we were aware of, but value-based care has really evolved into a healthcare landscape of its own with a wide range of organizations contributing to systematic changes that improve quality of care and outcomes while better controlling costs.

And so, providers are specializing in value-based care [and] have become really attractive to investors. I think that's something that we're all familiar with, and that's really because of the distinctive quality of care that can be provided. And then there's obviously opportunity that they present with the diversity of risk levels and business models.

And by building on this decade, as I said, it's been a long time coming of increasing value-based payment adoption and combining that with value-based capabilities across payers, providers, employers and other healthcare stakeholders lead to continued traction in the value-based care market. That could lead to — I think one report I saw said that there's a valuation of $1 trillion in enterprise value for payers, providers and investors.

So, with the stage set, and with that introduction, I want to introduce everybody to our guests.

I am joined by Ryan Langdale and Mike Brown from Chartis, who recently published a report titled "Unlocking Value in Cancer Care," where they explore how alternative payment models and "payviders," as they're called, and digital solutions are advancing value-based oncology.

And we're also joined by my colleague Daniel Patten, who is a partner in our firm's healthcare regulatory group. And he's joining us for the conversation given his practice's increasing focus on working with clients in the value-based care setting.

So, with that, welcome to the show everyone.

Ryan Langdale: Thank you for having us.

Mike Brown: Thank you.

Daniel Patten: Thanks, Morgan.

Morgan Ribeiro: So I think it's important before we jump into the report, really want to lay the foundation for our listeners. Stakeholders in the healthcare community define value-based care differently depending on who you're talking to. One thing I was reading says that Healthcare Payment Learning & Action Network, LAN, includes performance, reporting and even infrastructure in its first step of value-based care, while others note these models fall short of delivering value because they don't remedy the problems of fee-for-service healthcare.

So I think there's a little bit of conversation in the industry about what is value-based care. I think it's this terminology that gets thrown around a lot, and so before we get into talking about specifically oncology care and oncology value-based care, would love for each of you just to provide a definition of what is value-based care.

Ryan Langdale: Sure. I think re-grounding in the premise is important. If you heard one definition, you've heard one definition for value-based care. And the reason I think it's important is it's often reduced in our conversations to a one-sided discussion about cost in the form of shared savings and total medical expense and all the interventions that we use to drive down cost, but while that's a critical part of it, it's only half of the value quotient — cost and quality. And so as we talk about it and think about it at Chartis, it's really about optimizing that relationship between the quality of the care that's offered and the cost of the delivery.

Mike and I spend all of our time in cancer care. And so that quality has a lot of dimensions. It's notoriously hard to measure, to talk about what are measures of process in cancer care. Was my care timely? Were my interactions well navigated? And then there are measures of outcomes, and that gets into an even more difficult space. Did I experience complications? Was my financial toxicity managed well? Did the care I get fundamentally give me the best chance to control my disease and return to health and normalcy?

So, it's a challenging part, and there's a reason why cost gets sort of a disproportionate focus, but as we get into it, it will be interesting to kind of talk about both sides of that as part of the value quotient.

Mike Brown: I agree with everything Ryan said.

And I think — as he pointed out, we spend a lot of our time working in the cancer care space. And I have traditionally ascribed to a more academic definition of value being cost over quality and the outcomes associated with it. More and more over the last couple of years though, I think, we're increasingly seeing the importance of adding equity to that equation as well, and ensuring care is equitable across populations — that care is accessible across populations. So, I think organizations that are delivering really good single-point cancer care — and even if it's affordable — are missing the broader landscape around providing care that's equitable to broader populations. I think that we're missing the mark. I do think, not to use a cancer pun, but it's an important thing to infuse into the conversation around value.

Daniel Patten: I agree with everything said.

I've been asked to define this multiple times, and everyone has a different name for value-based care. You could give a definition, someone would come up with a different terminology for it, but I think kind of the themes here are obviously outcomes-focused, increase quality, the cost and the risk shift are obviously key, but really I view it simply as this move away from this fee-for-service individual patient-oriented approach. Right? You're trying to find these economies of scales and recognizing it's more than a one-size-fits-all approach, and we need to have this larger scale to get that done. So it's a transformation provider, just one doctor hanging up a shingle to understanding that this is a coordinated, collaborative effort to really take care of the whole patient.

Morgan Ribeiro: Perfect. Thank you all for that. And now more specifically on the oncology side, what is driving the increasing development, particular to that sector in that space?

Ryan, you mentioned in the beginning about just the collaboration that has to happen across a number of different providers, and so it does seem like this particular sector of healthcare is ripe for some of the benefits that can be seen through value-based care.

Ryan Langdale: Yeah. Morgan, maybe I can address why it's getting a lot of attention right now in cancer and then maybe have Mike follow up with the why it's hard to do in cancer. And you're getting at one of those things — the multidisciplinary nature. Interest is largely a derivative of the unsustainable trajectory of cost of cancer care.

It's about a billion-dollar industry right now as of 2023. It's expected to go to $300 billion by the end of this decade, and I think more practically speaking for the individual patient, the first year of therapy often exceeds the median household income in the United States. So we're talking about serious financial burden for folks that go through this.

There's a number of drivers [that] value-based care is attempting to sort of attack and deal with. One of those is the market price for drugs. Those things have come up 700 percent in just 20 years. In certain care environments, the cost gets further marked up by 200 and 300 percent. And then there is just a world of accumulated disutility around cancer care, being in a lot of environments fractured across a lot of specialties and just generally unmanaged or not managed well. And so there are a lot of stakeholders targeting those issues, from Medicare being one that I know Daniel's going to talk about here in a bit, in a lot of new entrants in this space, seeking to sort of provide models that transform for value and address some of these fundamental drivers.

I would probably start there as to why is there a lot of interest in this and why is there high visibility. Maybe Mike can follow on the challenges.

Mike Brown: Yeah. I don't think we should fault anyone for effort towards developing value-based strategy around cancer care by focusing on those components of it that are most costly, and perhaps most variable, across settings and provider groups. But it doesn't fully address the entirety of the cancer care continuum in a fully sufficient way when you imagine the fact that over half of cancer patients really begin their journey with a surgeon. And you're not getting to the medical oncologist, oftentimes, until you've already had some form of surgical intervention. And there's really no focus on whether or not that surgical intervention is provided in a quote, unquote "value-based environment" or even a high-quality environment in a lot of cases.

And so the impact that you're able to have downstream of the surgeon and the medical oncology specialty or with radiation therapy or in hospital-based services, up to and including end-of-life care, really represents the entirety of that care continuum. And I think that's a big part of the challenge. How do you really grapple with the multivariate nature of cancer care? But also at the same time really coming as an industry to fully understand and appreciate what a high-quality outcome is in cancer care because we focus primarily on good process leading to those strong outcomes, but if that outcome is, in fact, longer term survival and not necessarily as it is in some other cases, avoiding a readmission within 30 days of a surgical intervention. That's certainly a good outcome, but it's not really the outcome we're focused on in cancer care. So we've defaulted primarily to process-oriented measures to give us the quality component of the value proposition. And I think going forward there's going to be more and more focus placed on really bringing in the true outcome measures in cancer care that we need to see.

Morgan Ribeiro: That's great. OK, so Daniel, I want to shift gears to you.

In late June 2022, the Centers for Medicare and Medicaid Services, CMS Innovation Center, which is called CMMI, launched the Enhancing Oncology Model, EOM, which is an alternative payment model seeking to incentivize providers in oncology practices to offer whole person care while also providing value.

So, understanding that there's a lot of nuance to this, could you provide listeners with an overview of the landscape related to value-based cancer care and strategies that oncology providers can develop now to prepare for this changing reimbursement environment?

Daniel Patten: Yeah, Morgan. So, this EOM, this Enhancing Oncology Model is the next generation of CMS' innovation in the cancer world. A little more defined than efforts in the past, but what's clear is the focus is quality, quality, quality, right? We're talking about cost and outcomes-based, and I think that's important to notice from the get-go and reading all the literature around this item is patient quality.

It's also tech-driven. I think that we find in an interesting time the forced experiment of COVID, right? Medicare was in the dark ages with telehealth, in my opinion, and now everybody has a cell phone and a new expectation of what care delivery looks like. A few things I'll tell providers: First is it's a tech game. Everyone knows that, 21st century, so there's eight participant redesign activities in the EOM that participants, these physician practice groups, are going to have to implement. One of them, which I found most interesting, is a new one, which is electronic patient-reported outcomes. Right? There's a focus on using electronic means to really communicate with that patient.

We've talked a little about the subjectivity. There's cultural aspects of what is good care, how do you define that? Wanting to put the control back into a patient's hand and really having the touchpoint with those patients beyond when you're in the physician office. So understanding that implementing that is helpful. There's going to be a ramp-up, so start that now.

The next is the use of care partners' downstream amenities, essentially from participants in this program, and what does that look like? Ryan and Mike did a good job talking about what the difficulties [are] in providing value-based and oncology, but also why there's so many opportunities and why we're excited to get there.

How do you leverage others? This takes more than, I would say, even more than a village, right, to figure this out. It's going to take a huge team. It might find new areas, new collaboration partners. So experimenting with that now is going to be helpful.

Third is understanding anything risk-based. We're going to look to the law of averages, right? And scaling is going to be important. How is that feasible? We might have a good model, good thought, but how are we going to get there in trying to think about a plan?

Fourth, I would say is data-driven, right? Again, there's a lot of unknowns and a lot of uncertainty. You know, the underpinnings of value-based care is there's got to be a better way, let's find that. This kind of exploration mentality. And a lot of times you don't know what's important till later, right? So really the focus on data. As an attorney, I've been arguing and negotiating data provisions more and more recently as ransomware attacks are on the up.

And it's easy to kind of say, we don't need that now, let's pick a fight somewhere else, but I always push folks to continue to try to get as much data as possible that could help inform their decisions, their models, their goals.

And five is sustainability. A conversation I've had with a lot of individuals about this world is a risk-based shared savings model. At some point, you're competing against yourself, right? What does this look like in the long term? How is the model that you've created and the care delivery you've created going to be sustainable as you're essentially competing against yourself? And obviously, lowering cost is a high priority. Patient quality and outcome-focused processes are critical, but to be successful, sustainability is going to be key.

Does that answer your question, Morgan?

Morgan Ribeiro: Absolutely. Very helpful. And I think you summarized a pretty complicated topic really well.

So, as mentioned early on, obviously, the crux of our conversation is around the report that Chartis issued several weeks ago. You all released a similar report in 2022. I don't know that you all had planned to turn around and update that report so quickly, but it seemed like given the rapid progress in 2022, it was worth updating that report.

Can you highlight some of the changes or updates that you all have seen in the last year and what really drove you to say, "We need to update this report and put something fresh and new out there."

Ryan Langdale: Yeah, I can hit on a few of those. It's a really fluid space, to your point, Morgan. And so, I suspect there will be an end of 2023 version of this as well. We do expect continued activity this year along a number of dimensions.

One of the big ones was a lot of uncertainty coming into 2022 last year on what the future of Medicare's alternative payment models would be. The EOM, as Daniel just described, it did not exist yet. The headlines were that the previous alternative payment model for Medicare lost about $300 million over five years, and so there were legitimate questions around whether they were going to continue in this space of experimenting around alternative pain models in cancer care. They did come back with a refreshed version that's different in a number of ways, so they're hoping that it's going to yield a different result over the pilot period with this next program.

It does have a narrower eligibility set. There are a number of new requirements. It is going to again, be voluntary, but for those that participate, it will be mandatory two-sided risks. So there is no one-sided, upside-only version of the Medicare APM anymore. So that is a fundamental change that we have a lot of clients right now that are in the midst of preparing to participate starting this summer in that model.

There was also news from Medicare last year finally, that they were going to put the radiation oncology alternative payment model on permanent hiatus, which would've moved, in a mandatory fashion, 40 to 50 percent of the radiation oncologists in the country towards a bundled payment model across a number of different disease types and radiation oncology. So that one is on the shelf. I think that speaks to the ongoing uncertainty around what the future of these APMs are going to look like and what form they will take over time.

There are a number of other areas that I'm sure we'll get to in our conversation around extensions of what we call the "payvider" model in cancer with these practices that are more fully integrated or fully aligned on a risk basis with some of the big insurers, as well as a number of non-traditional players that have entered in the digital health space and the non-traditional provider space, to bring point solutions for various parts of the cancer continuum where there's common friction in the experience of getting care, and I think we'll get into that later in the discussion.

Those are the things that highlight as a rationale for why we felt the need to do a refresh after last year.

Mike Brown: The other thing I would add is we write this paper from the perspective of the investor-backed platforms in so many physician practices that are really thinking more frequently about the needs to move to a lower costs setting.

I think in a lot of ways the content in a paper like this becomes very informative to some of the larger health system and academic medical center clients that we have as well, who are admittedly and probably for the long haul, going to be a little bit behind the curve when it comes to implementing some of these value-based strategies. And so I think in a lot of ways it's also very informative to groups like that to ensure that they're keeping up with what's going on in the process. We encourage our clients, even if this is not something that you're going to be stepping into as an academic medical center or a large health system, need to be fully aware of what's going on in the market around you, or you're going to be disrupted to the point of non-existence in the relatively near future.

Morgan Ribeiro: That's a great point. Your competitors are not just the other hospital down the street, it's all the other players that are popping up.

Ryan, you mentioned alternative payment models, and on that front, the progress has been slow. Your report from last year highlighted the paucity of the two-sided risk arrangements in the cancer industry with alternative payment models, otherwise called APMs, generally referring to simple pathway compliance bonuses, supportive care stipends, enter one-sided retrospective risk models.

And in 2022, we saw the evolution of APMs as Medicare clarified the arc of its payment reform toward two-sided risk and commercial payers iterated on existing programs. And so I'm curious, what are some of the key points from your report that you'd want to highlight about the commercial APMs and Medicare APMs?

Ryan Langdale: I think on the Medicare part, it probably is simply that these programs will continue to be opt-in for the foreseeable future. Put another way, I don't think there are going to be broad mandates to move from fee-for-service to fee-for-value for cancer providers, although there will be plenty of opportunities in the near future to experiment and pilot that partnership with Medicare.

The second is that if you choose to pilot and partner with Medicare, you are going to do it in a two-sided risk world going forward. They have learned their lesson from the Oncology Care Model, some would say, around having one-sided risk, and so I think that's just the reality of some of the pilots now.

In the commercial space, there are still relatively few that are mandatory in any capacity. So you have examples of practices that are participating in shared savings programs or getting per-member, per-month payments to provide enhanced care coordination in an oncology medical home-esque structure, but those are not really at scale nationally yet. You know, while we expect to see continued movement in that space, a lot of the payer activity and value-based care has been more punitive in working to steer care into lower-cost settings as opposed to something more formal like the oncology care model or the enhanced oncology model with a value-based for an APM that's at scale. So I think that's probably what I would say is the state of things on the APMs.

Mike Brown: One of the things that I think the commercial players in this space are trying to move toward that's a little bit ahead of where CMS is — if you think about what's been proposed in the EOM, this is largely placing the responsibility of the physician practice on ensuring that lower-cost care. The adjudication of whether or not that's been done is retrospective, so we're looking back on care that was delivered over a period of time to determine if cost targets were achieved, and if so, bonus payments are made. A couple of the examples that are included in the paper — the Cancer Episode Program that United Healthcare is doing, some things that Signa has done, the City of Hope's Access Hope platform —  are really more prospective, I would say, in the way that they're intervening in that care delivery process.

And what I mean by that is that prior to the care being delivered, you could argue that these organizations are, in a way, partnering with the provider to ensure the right care is being delivered the first time around, and again, not placing the entirety of the responsibility on the physician practice, relying on the right pathway, etc., etc., when it comes to delivering that care. I do think that this is going to be something that we need to get towards more effectively if we're going to continue managing cancer care.

Going forward, both from a cost perspective and a quality perspective, the body of knowledge, as it relates to cancer therapy, is reproducing at a rate that's nearly impossible for any one individual to keep up with. And I think reliance upon, whether it's AI-driven support or expertise from quaternary centers, like City of Hope in the example that I just gave, around really disease site-specific expertise, is going to ensure that we're delivering the right care to patients, hopefully at cost and with high-quality outcomes as well.

Morgan Ribeiro: Great, and then the 2022 report highlighted the ways in which the healthcare ecosystem is moving towards this "payvider" model as payers are looking to influence, or they're looking to invest and own additional segments of the care continuum. Over the course of last year, we continue to see major interest in high-spend specialty areas, like cancer, and specifically in Medicare Advantage, which is a payer class disproportionately represented in the cancer population and expected to account for about half of all Medicare beneficiaries by the end of this year.

And so payvider activity generally fell into two broad categories: purpose-built, which is higher intensity, and then payer-owned models. Can you tell us more about the difference between those two models and any sort of changes that we saw in the last year?

Ryan Langdale: Yeah, I can describe those two categories. The payer-owned is quite literal. These are oncology practices owned by an insurer. The most prominent example to date is Optum Care, subsidiary of United Health Group. They've got full-service cancer centers in some markets like Las Vegas that have procedural medical oncology, radiation oncology, all under one roof in the classic sense of a cancer center. And then they have single specialists that they own by virtue of some of the acquisitions they've made of very large multi-specialty groups that have medical oncologists. So Kelsey-Seybold, The Everett Clinic, a few practices in Massachusetts that they bought last year. So they're assembling a big cancer presence as a payvider across the country in a number of different ways.

High intensity is the other category. It's our shorthand for models like Oncology Care Partners, which is a portfolio company of Welsh Carson and the Oncology Institute, which is traded publicly on the Nasdaq. These are models that are not owned by a payer, but the focus of their core business is taking risk alongside the payer and managing the total cost of care for the cancer patient, and so they have capitated and sub-capitated arrangements with other risk-bearing entities, and they take a pretty sharp focus generally in the Medicare advantage population only towards providing affordable clinically equivalent drugs when they're making decisions on what they prescribe. A high-touch model or high-touch interactions with cancer patients for care management to avoid things if they don't need to be in the ED, or having unwarranted admissions for things that could have been managed on an outpatient basis.

They have early interventions for palliative care, referrals to other like-minded value-based partners for other ancillary things that patients need, radiation oncology, imaging, et cetera. And so that's the high-intensity model. Again, closely working with and partnering with payers on a risk basis, but not owned by the payer per se.

Morgan Ribeiro: So what can we expect in 2023 as it relates to payers and risk-bearing primary care platforms, making this leap into value-based medical oncology?

Ryan Langdale: I think we're going to see growth in the existing platforms, certainly. I think TOI oncology care partners, with the capital they have, are certainly going be looking to grow into markets, and there are going to be markets that are Medicare Advantage just given the nature and the focus of those businesses.

So, I think that's a safe bet. I think we probably will see new entrants that are trying to replicate that model, until what is perceived to be a pretty big market need, especially on the part of some of these national platforms, these primary care practices that take a lot of risk and have certain specialties that contribute a lot to the total spin for their patient populations that they manage. And so we may see some of those risk-bearing primary care platforms looking to expand either through setting up versions of this high-intensity medical oncology practices and or partnering with environments where they think they can refer patients for a high-quality, cost-effective setting.

So I think that's generally my expectation for this year.

Mike Brown: I think on the primary care platform side of it, there's probably going to be a little bit of watchful waiting that goes on over the next couple of years. One example that I'm really curious to see how it plays out is the recent acquisition that Walgreens Village MD made of Summit Health.

In doing so you acquire a large multi-specialty physician practice in Summit Health, Village MD that, at least in northern New Jersey, also has a really significant multidisciplinary cancer program as well. And so, I think it will be an interesting test to see how capabilities within a value-based primary care platform are tested in terms of compatibility with delivering value-based cancer care or risk-bearing cancer care. To me that's one that's going to become an interesting one to watch.

Morgan Ribeiro: Great. Definitely the add-ons that we're going to see there. For those that have launched new platforms, I think we'll continue to see those grow. Ryan, like you had mentioned, we're certainly seeing that in our work with clients.

So the report last year concluded with an exploration of the levers of value.

I think we've touched on this a little bit in the beginning of the conversation, but recognizing that the most challenging element of value-based care oncology is the care model transformation necessary to generate the ultimate savings. Each of the levers that you explored — pathways, medical home models and digitally enabled care coordination — all made strides last year, including activity adjacent to the patient home. Can you speak more specifically to the progress made there in 2022?

Ryan Langdale: We talk about some of developments in space. The one that Mike and I do have a lot of conversation around, at least frequently, seems to be this notion of really good care coordination, and that's being facilitated by some of these newer entrants that are trying to do that digitally. Thyme Care is a good example of that.

 A comment that Mike said when we started this is by the time you're litigating the drug decision in medical oncology, you've missed a whole world of cancer care that preceded that. And so I think a lot of these newer platforms and many of the cancer centers that we work with, even in the academic setting that Mike talked about, are getting savvier to the fact that there's got to be really good end-to-end care coordination if you have any hope of facilitating a value-based care experience. So much of the dish utility and the delays and the cost and repeated unnecessary care can happen in the workup process of diagnostics, certainly in the surgical episode, and then equally during the more traditional six-month episode of chemotherapy that Medicare and others have focused on with the OCM and the EOM.

And Thyme Care is one of the many players that's tackling that. In July last year, they expanded their partnership with AmeriHealth New Jersey. So they have 300,000 covered lives now. They use a really unique model of leveraging the claim stater from the payer and advanced analytics that they have access to identify patients the first time a claim drops that has some hint of a suspicion of cancer, and they've got a team of navigators that connects with those patients and help them get through that panic period of going through a cancer diagnosis. And then ultimately, are our trusted advisor to patients to help steer them to cost-effective settings and to make value-based care decisions as they're going through their cancer care. So really a powerful model.

Jasper is another one that has been a similar space, have expanded their platform, announced a partnership last year with Scripps that we talked a bit about in the paper. Again, using connectivity via patient navigation. Patient-reported data, to the point Daniel made around ePROs, biometric data, symptom data to drive high-value outcomes. So that's one of many of the levers of value that we're seeing a lot of movement in.

Mike Brown: I think these levers of value end up getting pulled a little bit more as well going forward when we think about the other factors within the healthcare industry broadly that are necessitating a pretty meaningful care transformation. Specifically, I am speaking of workforce-related issues. We see that just as acutely in cancer as everywhere else. And so, when we're experiencing sort of generational shortages or cost constraints when it comes to the care team more broadly, I do think that those issues will also accelerate the development and deployment of things like medical homes, digitally enabled care coordination, et cetera.

Morgan Ribeiro: Great. And I know one thing that was also covered in the report, and looking at 2023 specifically, was related to digital care and the growing application of cancer care at home. I know we've talked to a number of companies and investors that are looking at this oncology care-at-home model. I think, of course, you talked to one company and they may partner with health systems to provide that, others are partnering with payers. So, each company is doing it a little bit differently. But curious to get your thoughts on what you might expect this year as it relates to digital care and the growing application of cancer care at home.

Mike Brown: I don't think that there is a single topic that is likely to get a more spirited conversation going amongst the cancer community than the notion of cancer care at home.

I think it is profoundly interesting at a philosophical level, and I think probably even on some practical levels when it comes to things like remote patient monitoring or certain services being delivered in the home, I think is a really meaningful and interesting idea.

I think we are, at best, tepid in our desire to see chemotherapy being delivered in the home setting. That said, there are a number of organizations out there that are really pushing the needle, and I think groups like Reimagine Care are doing really important things to stretch our thinking in this space. And whether or not the solution is that they ultimately provide —  or the way that they partner with organizations, payers or providers, is what prevails in the end. I do think it [is a] step in the right direction for all of us to be thinking about putting the patient really in the center of this equation, and I think I can probably speak for all of us in saying that I'd certainly prefer to be receiving care in my home versus in a sterile, cold hospital environment if in fact I knew it was safe and effective.

I think the push that we're going to have to face as well on this is creating the economic incentives that are necessary for providers to really step into this whole hog. I think that's going to be an issue for quite some time. But, again, it's the right step to take, and if we can learn from some of the things that are going on in other specialties, I think certainly the cancer community would embrace it at some point in future. It's a fascinating conversation.

Definitely gets people going at conferences, dinners or when we're talking with our client.

Ryan Langdale: I don’t have a whole lot to add to that other than to say that the process of navigating the uncertainty that Mike just talked about, listening to the consumer is going to be really important. So we've had some very fascinating conversations with clients of ours that are actively piloting chemotherapy in the home. So they've overcome economic challenges, the sort of operating challenges, at least initially, the safety concerns around the small subset of drugs that they feel comfortable doing in the home.

And the feedback has been that none of those are actually the challenge, and it was actually that the consumers involved in the pilot study didn't love the idea of having chemotherapy or cytotoxic chemicals in their home around their kids. There was a bit of cognitive dissonance around the seriousness of the disease and the casual nature of being treated in their armchair. Worries around there's no crash cart nearby. Are you sure this drug is safe? They hadn't expected to get that feedback.

By listening to consumers, they've actually discovered that as they advance that program, the obstacle they thought they were going to have to overcome aren't really the ones they thought going in. I think there will be continuous listening process with all of these things, and chemotherapy in the home is maybe the most extreme version of this. There are plenty of applications of doing a good job of monitoring symptoms and post-acute care and other things that can and are being done in the home. But as with many things, the chemo piece is more provocative and fun to talk about, and I think we'll continue to see versions of that and the digital enablement around that's going to be really important.

So, Reimagine Care will not be the only one targeting this space, certainly. It'll be fun to see the solutions that pop up around that, that start to facilitate a seamless experience between all the care environments, whether that's in the home, in the driveway, in a retail setting, in the hospital, in a physician office, et cetera.

Morgan Ribeiro: Great.

So from a legal perspective, Daniel, you've worked with a number of clients, either on the provider side or the investor side in this space. What considerations do these entities need to make as they're developing these new platforms like Reimagined Care?

There are plenty of opportunities, and I think these companies will continue to evolve as they partner with additional providers or partner with payers. But given this is still a relatively new frontier, there is likely a case of you don't know what you don't know. Learning as you go, but curious from your perspective, Daniel, things that they need to be mindful of as they're setting up these new entities.

Daniel Patten: This home-based chemotherapy, I think that's a great example. There's these new opportunities for providers that weren't previously there. Chemotherapy, traditionally, there's been a lot of restriction on the reimbursement side as opposed to a scope of practice side, that really kept chemo in a facility or an office-based setting. And so as we're seeing some of those restrictions on reimbursement come up, new questions arise. Is this acceptable? Is this a clinical decision? Looking at malpractice, looking at any type of litigation, it's bad outcome-driven, right? It's patient satisfaction and understanding the cultural need — I don't want to call it PR diligence, I think that undermines it — but understanding the patient, the vulnerable stay, these high acuity issues, having that at the center is key.

Maybe we can't take a leap in year one, but I think solely pushing and going there and getting the trust and understanding the patient and the cultural holdback that most of us, especially here in the U.S., have of expecting the best at all time, always need to keep that front and center, right? Clinical protocols are key.

Another thing I would say is anything's really on the table right now. Again, as I mentioned before, the great telehealth experiment of COVID-19 as an attorney in talking to investors or talking to new startups, I've seen more ideas in the last year than the rest of my practice combined.

It's seeing these new combinations that a lot of folks didn't realize were even possible. So being open to that, being open to partnerships, being open to folks outside the healthcare space, wellness is getting more and more interaction because that goes to patient satisfaction and getting that data or being in tune with a patient, giving those almost little perks that they really like. And at the end of the day, measuring quality, say, in oncology, dependent a lot on those more soft and subjective patient responses on that.

Those are the main items. Going back to what we mentioned before, you know, data needs to be a central focus, and any negotiation, but also a lot of folks I speak to think, how do I get in this space? I don't know about it. I don't want to go up against this big payer. Thinking they have a 200-page value-based care provider form at the ready. A lot of times this is new for both sides, so don't discount the novelty of your model or thoughts. I think there's an appetite on both sides to find something that works, both sides being the payer-provider and obviously for the benefit of the patient that reigns supreme.

But I've seen a lot of appetite from payers to start a brainstorming session, try to figure what works. I've seen companies say, here's our model, let's go forward. They have a conversation with a payer, they pivot, they go to the next payer, they pivot again, and they got four or five different models going right now.

And, you know, to close, we're always focused on outcomes. These are kind of short-term goals, right? When you look back, benchmark periods, when you're looking at program years, and when you're comparing it yourself, if the dollars are in the savings, right? How is this sustainable? And thinking through how can we implement something that's not going to be two, three years down the road, but really, if we're changing the system, how are we going to change it for good? I don't have the answer to that. If I did, it would be a much longer podcast.

Obviously, Ryan, Mike, no more than I could ever hope to know about this. But what struck me is just how many variations, how many different types of providers or payers. You know, Ryan mentioned in the beginning, the spend in oncology is so great, and that's what's driving a lot, is opportunity.

And so I find it very helpful to read these Chartis papers and clearly see in the paper, here are all the different folks getting involved. Here are the areas we're looking, these folks are concerned and really put a lot of clarity on the current landscape for me. So appreciate you guys sharing that with us.

Ryan Langdale: Yeah, appreciate you having us. We spent all of our time thinking about these things, and it's always a pleasure to talk to other folks about the things that we're passionate about, and ultimately finding solutions around this for a variety of different clients that we serve in our central lane and driving better cancer care, and, Daniel, to your point, superfluid space, right? Just as soon as you think you've got this figured out it changes. It's important to have these conversations frequently so you can stay on top of everything that's going on in this space. So, thanks for having us on.

Morgan Ribeiro: Thanks for joining us.

Mike Brown: Real pleasure. Thank you.

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