Climbing the Ladder to Tomorrow, One Rung at a Time

No matter how high you want to go, you have to step on that first rung of the ladder. Every oncology practice in the country is making plans to move forward in some direction, and will have to climb a ladder, one step at a time.

Oncology care is delivered in myriad formats and systems, including through private, hospital-based, academic, and even commercial centers. There is not one “right” solution. Each setting has already evolved in a certain direction, and many of the models being tried are geared toward specific formats or health systems; these may or may not be adaptable to other settings.

Many pilots and programs are currently being utilized in the oncology community, yet those involve only a minority of practices. We read articles and hear stories about payer–provider collaborations, episode-­of-care pilots, oncology medical home projects, and others. The reality is that there are more regions without active models than there are regions with pilot programs in place. There are also tens of thousands of medical directors of employers and regional health plans who are responsible for oncology policy and who have not yet had one conversation with an oncology group about oncology care. There are hundreds of oncology practices that have not yet had one conversation with a payer beyond traditional contracting negotiations. It is easy for very good practices struggling to keep up with the vicissitudes of daily operations to wonder if they are behind, or missing out on something.

Those medical directors and practices are not behind—they are just budding opportunities waiting to happen. We are learning that getting to the point of executing some of these pilots is a lengthy process. Those journeys start with an initial meeting, then progress through a delicate dance of mutual learning and understanding, and finally the slow blossoming of trust between providers and those who pay for medical services (eg, employers or health plans).

It is important to know that this process does take time, and that the initial meeting is going to be awkward. Payers and providers are both affected by oncology care choices, but in different ways, and both hold the needs of—and impact on—the patient as the highest priority. Too often, payer medical directors have little direct understanding of oncology as a specialty. However, they will have opinions and concerns regarding the treatment of cancer.

Too often the first inclination of the provider preparing for that first meeting is to develop a litany of their own concerns, or examples of where payments are underwater or need to be increased. This is not a good conversation for the first meeting. A better strategy for all involved is to make the initial meeting last ≤1 hour, and to spend that time listening to each other and finding mutual ground. Hot-button issues should be identified for the payer or employer, and the practice should express its interest and value as a partner and resource regarding oncology issues. These are the building blocks of a relationship, and the essential first rung on the ladder toward collaboration and mutually supported oncology management for patients in the local market. It is often useful to engage a neutral facilitator with a solid understanding and credibility in both the payer and oncology markets to help prepare for the first few meetings.

At the next meeting, both parties should come prepared with data they would like to share, based on the direction provided by earlier discussions. From these and subsequent discussions, projects, and eventually pilots, will evolve. These early meetings are not the time to jump into plans for oncology medical homes or episodic care payments. Those are far more complicated models that will evolve as possible solutions down the road, once a good relationship has been established.

If your group is watching the news and conference discussions about oncology medical homes or other pilot and payment reform models, and is not one of the early participants, take a deep breath. Watch and learn from the presentations, and start to evaluate what changes you would like to adopt in your own practice to prepare for eventual participation. Then, stop and look at your own local market. What is going on? Who are the top 3 to 5 business groups, employers, or health plans with whom you would like to develop a closer relationship? What can you offer them as a resource on cancer? Reach out to them and listen. You will have just completed the first rung on the ladder toward your own local oncology market reform, and it is a strong start.

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