Oncology service utilization has jumped in 2021 relative to 2020, but it’s still significantly depressed from its 2019 pre-pandemic levels. That means life sciences companies need to shift tactics — looking at screening and diagnosis regionally and at socioeconomic factors that contribute to incidence — in order to partner with providers and help patients, experts say.
Market access experts and an oncologist who spoke on July 22 at a webinar sponsored by consulting firm Avalere Health, an Inovalon company, laid out data showing that oncology service utilization and patient flow has increased in early 2021 relative to the same months in 2020 but has not nearly rebounded completely to its levels in 2019.
For example, Avalere data show colorectal cancer-related evaluation and management visits were 90% greater in April 2021 compared with April 2020. However, that same category of oncology visits was 40% lower in April 2021 compared with April 2019.
This roughly tracks with what oncology clinics are seeing, said Jeffrey Patton, M.D., CEO of OneOncology, a Nashville, Tenn.-based firm that invests in and partners with community oncology practices. “The post-COVID opening is not evenly spread across the country. There are places that are more open than others, so we have clinics where their rough numbers are up even more. And then we have clinics that are depressed more than this. There’s still an issue with access or people being willing to go see their provider,” he told the webinar audience.
It’s not clear when oncology — and other specialty areas — will return to 2019 utilization levels, said Lance Grady, practice director at Avalere. And, he told the webinar audience, “just trying to get back to 2019 may not necessarily be the right step. When we look at the patient journey and we look at some of this data, while we are comparing to 2019, we still had significant burden of illness in colorectal cancer in 2019 and other diseases.”
The dynamics of this disrupted market are driving consolidation and different partnerships and should drive how life sciences companies should deploy their resources, Grady said. “There is no doubt that the business model of generating demand and sales has been substantially disrupted.” Medical science liaisons (MSLs), account executives, sales representatives and reimbursement managers are working from home, he noted, but “are they doing that differently regionally?” They should be working differently in different regions of the country, depending on needs that vary by area, he maintained.
Overall, post-pandemic thinking should be different than pre-pandemic business as usual, Grady said. For example, “we’re working right now with one company that does not have a companion diagnostic for their oncolytic, but they are still thinking about a screening team. They’re still thinking about building a nurse or an MSL team that is focused on the patient journey and the intervention there. But there are not many [companies] doing that.”
It’s also clear that life sciences companies — and health care generally — need to make changes in how they address racial disparities, asserted Patton. “I think COVID has shined a light on two things,” he said. “One, our populations weren’t getting screened at the rate they should have before COVID, and that got worse. And health disparities existed before, and they’re still here. So I think as we look at the continuum of care and total cost of care, that life sciences companies are going to need to go upstream and be involved in education — education about screening and about the disease process and about health disparities — and be more involved in the community, instead of just waiting at the end of the funnel for what comes out when patients get diagnosed.”
Life sciences companies “need to be more conditioned to think like health care providers and health care companies,” Patton said. “Why don’t we focus on health and preventing disease, as opposed to just being rescuers and waiting for folks to get really bad diseases and treat them at that point? So I think focusing upstream and being more holistic in our approach to disease and health is really a good place to start.”
Nathan Markward, managing director at Avalere, said that the solutions — “moving access back to pre-pandemic normal” — likely will vary depending on the region or locality. “Overall, we’re still not back where we left off, and I think that’s the important key, both from the standpoint of diagnosis but also disease management downstream. It’s been very encouraging, especially the last couple of months, and we expect that with more recent data that this will continue. But nevertheless, there’s still work to do to make up for lost ground,” he told the webinar audience.
“Short to medium term, we’re seeing a huge impact on the influx of patients who have not sought care as early as they would have in the past,” said Patton. “And so there’s stage migration — we’re seeing a lot of unfortunate patients who would have presented in stage I or stage III that have metastatic disease.”
Avalere’s data seem to track with the concept of seeing more disease right now, since biopsies that follow screening colonoscopies are not as depressed as the screenings themselves, Grady said. Meanwhile, chemotherapeutic claims for colorectal cancer are still 54% lower in 2021 than they were compared with the same time frame in 2019, he said. “So when you think about points of intervention if you’re a payer or a life sciences company or a medical oncology provider, you not only address each intervention but what are the sum of all these parts as well,” said Grady.
The less-depressed biopsy rate probably comes from triaging patients who are symptomatic, Patton explained. However, delays in surgery and oncolytic therapy aren’t as easy to explain, although they may be related to post-pandemic queues for treatment.
Right now there’s “a diagnosis queue,” with patients who are in line to see gastroenterologists and then pathologists but who haven’t yet made it in to see oncologists, said Patton. “What I worry about are the gastroenterologists, who are the ones who are going to diagnose — they don’t have the capacity to see everyone at once. So I worry more about the diagnosis being flooded than I do the medical oncology offices’ capacity to take care of these patients.”
Still, he said, a queue for diagnosis and disruptions in the timing and sequencing of care are unlikely to be a permanent effect of COVID-19. Nonetheless, “I hope it helps us learn to appreciate that our 2019 baseline for screening and access to care was not perfect. Hopefully this will shine a light on the fact that if you don’t get screened, your chances of having more advanced disease are higher,” he said.
Oncology isn’t the only specialty where care was deferred, stated Grady. For instance, “we looked at this last year, and EKG rates were just completely bottomed out,” he said. “That is also a big concern right now and something we’re watching in our data: the rate of rebound on EKG and the burden of illness and cardiovascular disease.”
Community Partnerships Are Urged
As a result of the pandemic, utilization shifted away from hospital-based cancer care and more toward community-based care, Patton said. “In oncology, we’ve had a long history of taking care of very vulnerable patients, and this has helped us realize just how vulnerable our patients are,” he said. Consolidation in health care has been occurring for years, and the pandemic has accelerated this trend, especially in smaller practices that were particularly impacted when patients deferred care due to fear of contracting COVID-19, he noted. In addition, “as hospitals devoted their resources to COVID, they weren’t able to afford to use their resources in oncology care.”
Care is likely to shift back toward the hospital setting as the pandemic winds down and hospital resources are freed up, said Patton. Still, the pandemic-era shift toward the community setting “does bring up discussions that we’ve had in some of our markets with a better partnership between community-based oncology providers and hospital-based providers. This could be a side effect of COVID that it will push us together to work more cooperatively and foster a different delivery system,” he said.
This issue is applicable to the matter of how life sciences companies might engage oncology providers and also to their overall external engagement strategy, contended Grady. “We’re focused on multichannel types of conversations,” he explained. Thinking locally also is critical: “How a good brand strategy or a good tumor strategy or a good product positioning strategy resonates in Detroit vs. Arlington, Texas, involves two different dynamics.”
Local strategies should differentially drive resources through advocacy or through local connections and potentially could address issues such as transportation, screening rates or disproportionate disease burdens in one geography vs. another, Grady said. “This is certainly where strategic brand planning and strategic market access are critical. But post-pandemic, the nuanced approach or the market strategy here, including the ability to differentially shift resources, is the learning and likely needs to be the strategy moving forward. I think if you talk to most health care providers, they would welcome that, as well.”
Life sciences companies may want to consider putting more advocacy and energy toward referral patterns, screening patterns and upstream interventions, as opposed to simply focusing on patients who present at the point of treatment or patients who currently are in treatment, he said.
Most likely, very few oncology biopharmaceutical manufacturers currently have resources pointed at gastroenterology, as opposed to oncology, he said. “The resources, the marketing, the promotion, the intervention is as the patient presents,” explained Grady. “When you think about your patient support services strategy, certainly there are limitations to what you might do, particularly in a branded program. In a nonbranded patient support services program or one that is also connected to a broader advocacy strategy, there are multiple ways to intervene.” Charitable giving strategies via a 501(c)(3) nonprofit are one way to accomplish this but not the only way, he said.
“We recently just completed some primary research and an analysis for a client who wants to better understand care patterns and patient intervention support in CAR-T [i.e., chimeric antigen receptor T cell],” stated Grady. “As cell therapy moves into the community, there are substantial needs of that patient journey. I think this idea of when to engage and what to engage through is not new, but the priority of it has certainly been ratcheted up. These are some areas that I think quite frankly have not been as prioritized in pre-pandemic times but now will likely cause life sciences companies to act differently.”
Telemedicine is one area that boomed during the COVID-19 pandemic, and many stakeholders expect its role in care generally to be much expanded going forward. However, it may not see as much use in oncology, Patton said. “It could be a complementary role, but if you’re going to get therapy in the office, you’re going to get a scan at the hospital, you’re going to get laboratory [services] in the office, you’re going to be there anyway. I think the role [for telemedicine] will be more in surveillance of patients who are doing well. So there’s a role, [but] it’s not a panacea. I think patients, even surveillance patients, they like seeing and touching their doctor to get that reassurance that their cancer’s still gone.”
One possible use for telemedicine is remote screening for clinical trials, said Patton. “You can have that education session and screening process happen via telehealth before they come to the office. That’s an area where we used telehealth during the pandemic that I think will last and can be expanded.”
The pandemic had unexpected effects on clinical trial enrollment itself, he said. At first, surveillance patients were told not to come to the office, and so providers had more time to spend with patients in active treatment, and clinical trial enrollment rose. However, within two or three months, sponsors closed down the trials because they were concerned that COVID could interject confounding variables into the trial outcomes, he said. Overall, “it did teach us that it does require effort and time for providers to spend the time with patients and get them enrolled in clinical trials. I think that’s something that should be talked about post-pandemic: finding a way to have either protected time or incentives or other ways to allow providers to focus on clinical trial enrollment.”
Value-Based Programs Ramp Up Again
The public health emergency and pandemic-related volatility in oncologic care led to the Center for Medicare & Medicaid Innovation (CMMI) decision to pause some downside risk options in its Oncology Care Model, which includes episodes of care surrounding chemotherapy administration to oncology patients, said Grady. UnitedHealthcare also “pressed pause” on its own episode of care program, he added.
However, these programs are coming back, he said, noting that CMS just unveiled proposed rules for its Radiation Oncology Model, a mandatory model that will test prospective, site-neutral, modality-agnostic, episode-based payments in specific locations across the country. That model is set to begin on Jan. 1.
It’s not clear how the case mix will present in that time frame, and it’s also not clear whether CMS has the correct risk adjustments and methodology to account for effects of the pandemic and for the potentially more advanced disease stages that oncologists may encounter.
“It’s not just about the price or the total cost of care, but it is also about that patient journey across that sort-of medical home model,” Grady pointed out, noting that these new episode-of-care-based payment systems will likely lead to new provider affiliations and partnerships as providers take on more risk and as payers think about how they want to manage oncology risk more broadly.
Since reimbursement is shifting to value-based care that encompasses the total cost of care of all interventions, the critical next step is to consider how case mix is changing and progressing post-pandemic, particularly given that patients may be presenting with more advanced disease in 2021, he said.
It’s well-known that the pandemic exacerbated — and shone a spotlight on — disparities in racial outcomes and social determinants of health, Markward said. This also is shown in CMS data Avalere has analyzed on advanced oncolytic disease: In 2020, African Americans presented with advanced disease at nearly four times the rate of white Medicare beneficiaries. The data show that overall, 0.3% more beneficiaries had initiation of an advanced oncolytic regimen as first-line treatment in 2020 as compared with 2019. But when broken down by race, the increase was 0.3% in white patients and 1.1% in Black patients. Understanding these disparities can help to determine where resources can be targeted to “get a better bang for the buck,” he stated.
Added Grady, “I think to the degree that this also becomes a differential in terms of response rates or a differential in terms of disease progression, this could also be a potential clinical trial strategy, clinical development strategy or potential real-world-evidence strategy to try to further understand.”
Overall, as specialty care moves from fee-for-service to episodic payment, or even if some services remain in fee-for-service but also have geographic adjustments added, valuation of codes needs to be carefully considered as companies set prices to get to a target, asserted Grady. Avalere has advocated for using social determinants of health as a risk adjustment and is working with payers, providers and pharmaceutical manufacturers on how to accomplish that, he said.
by Jane Anderson