The Role of ACOs in Chronic Lymphocytic Leukemia


Expert panelists provide their perspectives on the role of accountable care organizations (ACOs) in oncology care for patients with chronic lymphocytic leukemia.


Troy Trygstad, PharmD, PhD, MBA: I grew up on the primary care side, and I’m very familiar with accountable care organizations and payment reform. I had the opportunity to participate in the 646 Demonstration waiver, so that’s your trivia for the night, which was the first shared savings program of Medicare’s history in 2006. And I’m very familiar with accountable care organizations because there’s this ethos within primary care of, How do I coordinate care? How is it that we feel like we can become the quarterback, these pharmacists and others, and do the same things we were talking about earlier, which are extending beyond the 4 walls of practice and doing population management and focusing on total cost of care and global outcomes. Coming up with bundled payment models, shared savings models, has been familiar in that space.

But a wise person once told me—and at Community Care of North Carolina, there are actually endocrinology clinics and some ID clinics that treat patients with HIV, and I’ve heard the same in oncology—that when you have a condition like HIV or an oncology condition, that becomes your coordinator, your medical home, so to speak. So it sounds to me like oncology is just starting to get into this payment reform space. Mike, what does a shared savings or a bundled payment model or an accountable care organization look like in oncology?

Michael Reff, RPh, MBA: I’ve got nothing on that.

Troy Trygstad, PharmD, PhD, MBA: So that’s one of the challenges, right? So for an accountable care organization that primary care is familiar with, coming to a high-risk, high-reward practice like an oncology practice is probably inevitable because we’re talking about the ability to have a large influence on their total cost of care, their hospitalization rate, and their survival. So Mayo Clinic works with bundled payments and shared savings, certainly within its primary care and with its plans. What does that model look like to you, Kirollos, in the oncology space? Can you imagine a space where you say, “We’re going to go at risk for some of this cost of care”?

Kirollos Hanna, PharmD, BCPS, BCOP: Obviously, this whole accountable care topic has been a dialogue over the past couple of years. Several institutions and payers are advocating for ordering the right tests, the right drugs, and avoiding ordering unnecessary tests. And I think right now where we are in all of this, we’re still very early in the oncology space to know the true benefit that has been seen out of this. Because just this year in the Journal of Clinical Oncology, there was an article published that looked at non-ACO organizations versus ACO organizations and the cost differences based on what was recommended. And there was no statistically significant difference in cost between the 2.

So I really think it’s fairly new, but it does go hand in hand with that medically integrated model in that if we’re able to address adverse effects early, optimize therapies early, give patients medication early, keep things within the health system, and leverage our EMR [electronic medical record] systems so we’re all communicating as a team, it will help the overall health care cost—because we continue to drive up cost again by unnecessary walls that we’re building within the health system. These unnecessary walls are that lack of communication among one another.

Troy Trygstad, PharmD, PhD, MBA: So the whole idea behind accountable care—whether the formality of accountable care organization or the informality of a contract that we have that really pushes down some risk for outcomes, whether they be survival, hospitalization costs, or getting to a certain lab result—is basically saying I’m the purchaser, I’m the employer, I’m the taxpayer, I’m the plan, I’m the plan sponsor. I want to have a circumstance where you’re telling me you can provide really good coordinated care and you can do this cost-effectively. Great, go do it. I want to have a contractual relationship with you that puts the money where the mouth is. Is that something that you would consider in your model of care?

Kirollos Hanna, PharmD, BCPS, BCOP: Absolutely. I would say let’s do it.

Troy Trygstad, PharmD, PhD, MBA: Christina?

Christina Patterson, PA-C: Yes.

Troy Trygstad, PharmD, PhD, MBA: Mike, what about your association?

Michael Reff, RPh, MBA: Yes, absolutely, and I’d like to build on that. So we have had conversations with payers, regional payers, to keep that continuity of care to go beyond the first fill at the practice level. But what we’re talking about here is a situation where we’re running at risk. And what I mean by that is on the medical side for the IV [intravenous] therapies, we’re able to infuse and bill, and things are normal. But what happens on the Part D side, or even from a whole holistic perspective on the oral side, is that the payers are not allowing us to necessarily always keep that prescription at the practice. And so we’re going at risk if a payer is going to hold us accountable for patient reported outcomes when we don’t have that continuity of care because that prescription is leaving the 4 walls.

So as an organization, we have partnered with 8 practices and 8 NCODA [National Community Oncology Dispensing Association] practices and gone to 11 regional payers and employer groups to convince them, based on a story of quality and value. We have provided the opportunity to keep that prescription with those payers and those employer groups, to keep that prescription at the site of care, at our practices. And based on that, we’re providing data back to the payer to demonstrate that quality and value.

And to Kirollos’ point, it’s in its infancy. It’s a small subset of the total oncology world. But it’s a start, and it’s a start in the right direction because by doing such, we’re seeing all the stakeholders in this space win. The patient certainly is winning with the continuity of care, speed of therapy, and better adverse event management. But the payer is winning because we’re taking cost out of the system, which is impacting the employer who’s paying the insurance company for that member’s insurance policy. So we’re taking cost out of the system and deriving better quality care at the same time.

Troy Trygstad, PharmD, PhD, MBA: It seems like a reasonable proposition to me. Essentially what’s in it for me is if you want to hold me accountable for these outcomes or these survival rates or these lab results, whatever that outcome of interest is that my performance or my risk is associated with, I need to be able to control this care.

Michael Reff, RPh, MBA: Absolutely.

Troy Trygstad, PharmD, PhD, MBA: Don’t expect me to manage care that I don’t have control over.

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