Unlocking the potential of biosimilars in oncology and value-based care models
THE SHIFT to value-based care is happening
Market drivers have prompted progressive organizations to move toward building an infrastructure and partnerships that support value-based care, including investing in alternative payment models. Although there is a high degree of uncertainty regarding the specific financial impact of these models on practices, many providers and payers enter these practice models in hopes of “developing the muscle” and effectively organizing to learn how to perform under these models before they become more widely disseminated and/or mandated. This shift from fee-for-service (FFS) to value-based care requires practices and providers to rethink their business model, undergo bold strategic repositioning, differentiate through innovation, diversify, and manage a population’s health risk.
In order to help rein in costs, improve care coordination, and help improve patient outcomes, the Centers for Medicare & Medicaid Services (CMS) are increasingly promoting alternative payment models to engage healthcare providers and health systems in sharing responsibility for the populations they serve and accepting financial risk for their performance. According to CMS, alternative payment models are a “specific subcategory of value-based purchasing initiatives that require providers to make fundamental changes in the way they provide care,” and they “shift financial incentives further away from volume by linking provider payments to both quality and total cost-of-care results.”
Examples of alternative payment models include bundled payments and using accountable care organizations (ACOs). “While Medicare has been the driving force in the national movement toward two-sided risk, where both provider and payer assume risk, state Medicaid programs, commercial health plans, and even employers are starting to adopt the model.” While some models were initiated by CMS through the Innovation Center, others have come from the private sector, but all have been extensively implemented.
The market shift to alternative payment models is here and now, driven by the pressure to reduce costs and improve outcomes. These new and emerging payment models are a fundamental component of delivering value.
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Providers leveraging alternative payment models are leading the way to value-based care. They understand the importance of its availability to advance outcomes and deliver cost savings.
Examples of Value-based Care in Action
Experts in population health who help mitigate the costs of health management by emphasizing chronic management as preventive care
Increasing numbers of accountable-care organizations that focus on cost containment and provide groups with specific health metrics to prevent complications that become costly
Employers taking a larger role in employee-plan–benefit design; for example, working with providers and employees to provide cost-effective therapies
Biosimilars being seen as a cost-effective strategy to increasing overall patient access to biologics
Biosimilars continuing to be recognized as a value-based alternative, as reflected by updates to treatment guidelines favoring the use of biosimilars
Delivery models that help improve care delivery and coordination
Oncology Care Model (OCM)
Encouraged OCM practices to improve care for beneficiaries and lower total cost
Monthly Enhanced Oncology Services (MEOS) that pay for enhanced services for beneficiaries combined with the usual Medicare Fee-for-Service and the potential for a retrospective performance-based payment based on quality and savings
Enhancing Oncology Model (EOM)
Successor model to OCM (launched July 2023)
Builds on experiences from the OCM program and feedback from the oncology community to further advance the journey in value-based care in oncology
Includes 2 risk arrangements with differing levels of downside risk
