October 26, 2022, The Association of Value-Based Cancer Care (AVBCC) Summit in New York brought together payers, providers, and clinical oncologists to discuss critical cost-value issues impacting cancer treatments. The three-day conference featured panels on a variety of topics, including several moderated by ADVI Health’s Marc Samuels, JD, MPH, Lindsay Bealor Greenleaf, JD, MBA and Michael Kolodziej, MD.

The consensus among panelists was that the Inflation Reduction Act (IRA) and its forthcoming implementation presents a multitude of unknowns that stakeholders across the healthcare sector must unpack in the coming months following the midterm elections.

Marc Samuels summarized the key points from his panel stating, “AVBCC is a collage of shared experiences. This year those experiences culminated in raising awareness of how drug payment reform will impact patients, physicians, plans, and manufacturers brought by the recently passed IRA. The big learning thus far is that the impact of the government negotiation policy is beyond what happens to pricing. The ripple effects will be significant for the community practice, how it is reimbursed and ultimately whether it survives.”

Adding to this summation, Marc noted, other discussions on value-based constructs like subscriptions, warranties, reinsurance, and outcomes-based agreements won’t let a manufacturer escape the IRA but may be useful in blunting its impact in Medicaid or the commercial payer market. Cell and gene therapies may be innovative and breakthrough medicines, but as the IRA target list juggernaut picks up speed, these products may not be able to escape inclusion. And finally, by 2030, 16 oncology drugs will already fall victim.

For Lindsay Bealor Greenleaf, a key takeaway was that the IRA will ultimately force oncologists to become federal policy experts. Lindsay explained, while oncologists have always had to monitor coverage and payment developments related to their Medicare and Medicaid patients, with new IRA reforms, there will be significant financial implications across all lines of business. “Even if you disregard the financial concerns, simply finding the time to analyze these changes is a massive burden for providers,” she said.

Panelist Steve Peskin, MD, MBA, MACP, former Executive Medical Director with Horizon Blue Cross Blue Shield of New Jersey, noted takeaways from a panel focused on pediatric medicine exploring how the industry will financially support pediatric cancer care. Panelists highlighted the realities that families and caregivers of pediatric cancer patients have to miss work and are unable to pay for non-covered services. While there is research on emerging immuno-oncology agents for cancer therapy, there is limited funding.

During a panel highlighting the Oncology Care Model (OCM) and how best practices should be incorporated into the Enhancing Oncology Model (EOM), speakers explored several lessons learned. Panelists agreed that while the OCM was not a perfect model, there was value in the model and that it has in fact contributed to timely learnings that helped keep patients out of the hospital.

Serving as a moderator on multiple panels spanning the conference, Dr. Kolodziej noted four candid takeaways:

1. Payers still don’t have a lot of new ideas. They are convinced the “old ways” like prior authorization still work.
2. People really liked OCM and consider it a success. As such, they are having a hard time conceding the financial losses or are ready to explain them away.
3. It is not clear what will happen in the EOM. As we have been saying, the big practices are all in. It is likely the small ones are not.
4. The biopharmaceutical industry is focused on the IRA; however, most payers and providers haven’t really thought too much about it.

 

As stakeholders across our industry anticipate more integration of value-based approaches and the impending implementation of IRA, it’s imperative to continue to delve further into these questions as well as to commit to the planning necessary to navigate this new era in healthcare.