The implementation of value-based frameworks, clinical care pathways, and alternative payment models for cancer care in the United States

Abstract

BACKGROUND: Cancer treatment is a significant driver of rising health care costs in the United States, where the annual cost of cancer care is estimated to reach $246 billion in 2030. As a result, cancer centers are considering moving away from fee-for-service models and transitioning to value-based care models, including value-based frameworks (VBFs), clinical care pathways (CCPs), and alternative payment models (APMs).

OBJECTIVE: To assess the barriers and motivations for using value-based care models from the perspectives of physicians and quality officers (QOs) at US cancer centers.

METHODS: Sites were recruited from cancer centers in the Midwest, Northeast, South, and West regions in a 15/15/20/10 relative distribution. Cancer centers were identified based on prior research relationships and known participation in the Oncology Care Model or other APMs. Based on a literature search, multiple choice and open-ended questions were developed for the survey. A link to the survey was emailed to hematologists/oncologists and QOs at academic and community cancer centers from August to November 2020. Results were summarized using descriptive statistics.

RESULTS: A total of 136 sites were contacted; 28 (21%) centers returned completed surveys, which were included in the final analysis. 45 surveys (23 from community centers, 22 from academic centers) were completed: 59% (26/44), 76% (34/45), and 67% (30/45) of physicians/QOs respondents had used or implemented a VBF, CCP, and APM, respectively. The top motivator for VBF use was “producing real-world data for providers, payers, and patients” (50% [13/26]). Among those not using CCPs, the most common barrier was a “lack of consensus on pathway choices” (64% [7/11]). For APMs, the most common difficulty was that “innovations in health care services and therapies must be adopted at the site’s own financial risk” (27% [8/30]).

CONCLUSIONS: The ability to measure improvements in cancer health outcomes was a large motivator for implementing value-based models. However, heterogeneity in practice size, limited resources, and potential increase in costs were possible barriers to implementation. Payers need to be willing to negotiate with cancer centers and providers to implement the payment model that will most benefit patients. The future integration of VBFs, CCPs, and APMs will depend on reducing the complexity and burden of implementation.

DISCLOSURES :Dr Panchal was affiliated with the University of Utah at the time this study was conducted and discloses current employment with ZS. Dr McBride discloses employment with Bristol Myers Squibb. Dr Huggar and Dr Copher report employment, stock, and other ownership interests in Bristol Myers Squibb. The other authors have no competing interests to disclose.

This study was funded by an unrestricted research grant from Bristol Myers Squibb to the University of Utah.

Plain language summary

Cancer centers frequently charge fees based on services provided to patients. To lower costs but keep quality of care high, many are trying new payment models. Fees may be based on patient outcomes, treatment plan, or quality of care. We surveyed 45 physicians and quality officers at 28 US cancer centers. Some said these new models work well and lead to better care. Problems include resources, agreeing on care pathways, and financial risks.

Implications for managed care pharmacy

To reduce the high cost of cancer care, cancer centers are considering adopting value-based care models. Differences in practice size, limited resources, and a potential increase in costs make this change difficult. Payers (ie, health insurance companies and federal and state governments) should be willing to negotiate with cancer centers to help set up a payment model that will most benefit patients.

The estimated annual cost of cancer care in the United States is expected to reach $246 billion in 2030.¹ Cancer care delivery models vary by practice site, including community-based practices, cancer centers affiliated with large academic institutions, and integrated delivery networks. Cancer centers use different care models to deliver primary cancer treatment, supportive care, and survivorship services. However, rising costs have compelled cancer centers and payers to re-evaluate traditional volume-based, fee-for-service models and consider new oncology care payment models.

One type of oncology care payment model is the value-based framework (VBF). VBFs are formal structures to evaluate clinical and economic evidence to guide health care decision making among physicians, patients, and payers. Health care organizations developed VBFs to measure and compare the value of treatment benefits with costs. Examples of VBFs include the National Comprehensive Cancer Network (NCCN) Evidence Blocks (https://www.nccn.org/guidelines/guidelines-with-evidence-blocks) and the American Society of Clinical Oncology (ASCO) Value Framework.^2,3

Another type of oncology care payment model is the clinical care pathway (CCP). CCPs are based on evidence-based protocols and direct prescribers to the most cost-effective treatment regimens. Their aim is to minimize unnecessary variation in treatment patterns and improve quality of care while reducing costs.^4,5 Examples include the NCCN clinical guidelines and vendor-developed clinical pathways, such as ClinicalPath (formerly Via Oncology; https://www.elsevier.com/en-gb/solutions/clinicalpath), the NantHealth Eviti oncology clinical decision support and treatment validation platform (https://connect.eviti.com/Connect/Support/OurMissionForm.aspx), and the eviCore Comprehensive Oncology Suite (https://www.evicore.com/solutions/health-plan/utilization-management/medical-oncology).

The third type of oncology care payment model evaluated is the alternative payment model (APM). Recently, the use of APMs has increased.⁶ Payers recognize the need to work with health care providers to modify payment structures to better incentivize providers to deliver high-quality care,⁷ and APMs encourage cost-efficient care. Examples of APMs include the accountable care organization (ACO) (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO), patient-centered medical home (PCMH) (https://www.cdc.gov/dhdsp/policy_resources/pcmh.htm), and Oncology Care Model (OCM) (https://innovation.cms.gov/innovation-models/oncology-care).^8,9 Whereas the OCM focuses on discrete episodes of care, the ACO and PCMH models focus on overall care at the higher population level. The OCM was active from 2016 to 2022 and is currently being replaced by the Enhancing Oncology Model (EOM) (https://innovation.cms.gov/innovation-models/enhancing-oncology-model). One of the key goals of the EOM is to build on the lessons learned from the OCM and make it more relevant to current patient needs and preferences.

Based on the practice setting (including size, type, administrative policies, resources, and infrastructure), there can be both barriers and motivations for implementing care delivery or payment models. The aim of this study was to identify barriers and motivations associated specifically with using VBFs, CCPs, and APMs, implementing them, or both from the perspective of physicians and quality officers (QOs) at academic and community cancer centers in the United States. A better understanding of these barriers and motivations could inform strategies for cancer centers to increase the use of VBFs, CCPs, and APMs, which, in turn, could improve outcomes and reduce costs in cancer care.

Methods

This was a national, multicenter survey study. Sites were recruited from cancer centers in the Midwest, Northeast, South, and West regions with a 15/15/20/10 relative distribution.¹⁰ This distribution was selected based on the sixth annual ASCO Oncology Practice Census survey, which categorized practices according to the geographic region, number of oncologists, and number and rurality of sites. Sites from the Centers for Medicare & Medicaid Services–provided Physician Compare dataset, which helps consumers compare clinicians and institutions enrolled in Medicare,¹¹ were also included. Cancer centers were chosen based on prior research relationships, known participation in OCM or other APMs, and merit-based incentive payment systems.

Participants were invited by email to complete a survey specific for either physicians or QOs about their experiences using VBFs, CCPs, and/or APMs, implementing them, or both at their respective cancer centers. The physician had to be a practicing hematologist or oncologist. The QO was required to hold a “Quality Officer,” “Practice Administrator,” or equivalent job title (eg, quality administrator). Although respondents self-identified as a QO, it was expected that participating QOs were involved in overseeing quality performance initiatives at their institution, such as VBFs, CCPs, and APMs. One physician and 1 QO per site were allowed to participate. Physicians at each institution were selected based on the available contact information. The email included the study objectives, inclusion criteria, explanation of the $500 honorarium to the institution, and a unique link to the physician/QO surveys. If the physician or QO was not able to complete the survey (typically because of a lack of experience with value-based care models), they could forward the email to a colleague at the same center whom they thought would be better qualified. Three reminders were sent to participants during a 2-week period before the survey link expired. Survey dissemination occurred from August to November 2020.

SURVEY DEVELOPMENT

A literature review in PubMed and EMBASE was conducted to inform the physician and QO surveys. The search strategy included the following keywords: “alternative payment models,” “APM,” “value-based frameworks,” “VBF,” “clinical care pathways,” “CCP,” “oncology care model,” “OCM,” “accountable care organizations,” “ACO,” “quality measures,” “quality initiatives” and “oncology,” “cancer,” and “cancers” or “cancer care.” Studies were required to include information about VBFs, CCPs, or APMs in cancer care, be published within the last 10 years, and be restricted to US studies and the English language.

The literature search and expert consultation identified potential barriers and motivations related to the implementation of a VBF, CCP, or APM. Each survey included multiple choice, open-ended, and rank-based questions (scored from 1 to 5), which were used to identify the least and most impactful barriers and motivations.

The survey included sections that focused on VBFs, CCPs, and APMs, specifically. An introduction for each section included key definitions and examples of each model that are commonly used in practice. In addition, an external link to view a comparison of the models in oncology was included.¹² Expert consultation and testing with practicing hematologists/oncologists, quality administrators, and content experts was also incorporated. The survey was built in Qualtrics, a University of Utah–approved electronic survey platform, and tested for functionality before dissemination.

The physician and QO surveys included 57- and 79-item questions, respectively (see Supplementary Exhibit 1, available in online article). The first 57 questions were identical for both surveys; the QO survey included 22 additional questions, which asked about quality measures, economic outcomes, incentives, impact on physicians, and data analysis.

STATISTICAL ANALYSIS

Only completed surveys were included in the final analysis. Categorical variables, such as multiple choice questions, were reported with descriptive statistics using counts and percentages. Noncategorical variables, such as rank-based Likert scales, were reported using medians and interquartile ranges (IQRs). For questions ranking the most/least impactful motivation or barrier, responses were presented as counts and percentages. Open-ended questions, such as the length of time for implementation, were reported as median and IQR. Open-ended questions describing other barriers or other opportunities associated with the implementation of VBFs, CCPs, or APMs are listed separately in Supplementary Exhibit 1. Responses were stratified by the type of cancer center (academic or community) and the type of responder (physician or QO); however, because of sample size limitations, no formal comparisons between types of cancer centers or type of responders were conducted.

ETHICS APPROVAL AND INFORMED CONSENT

This study was reviewed by the University of Utah’s Institutional Review Board, which determined it to be non-human subject research and granted an “acknowledged designation” under IRB_00127943.

Results

Of the 136 cancer center sites initially contacted (78 community sites and 58 academic sites), physicians and QOs at 28 sites completed the surveys (21% response rate). The distribution of response was similar, with physicians and QOs from 15 community cancer centers (19%) and 13 academic cancer centers (22%) providing complete surveys. A total of 45 survey responses (22 from academic sites, 23 from community sites) were received. Among the surveys that were returned, there were 10 physicians (22%) and 13 QOs (29%) from community cancer centers, and 13 physicians (29%) and 9 QOs (20%) from academic cancer centers. The 28 participating sites spanned the Northeast (6 [22%]), Midwest (7 [26%]), South (11 [39%]), and West (4 [15%]) (Table 1).

TABLE 1.

Summary of Recruitment and Response

	Community cancer centers	Academic cancer centers
Respondents
Surveys sent, n	162	124
Completed surveys, n (%)	23 (14)	22 (18)
Physicians who were sent survey, n	81	62
Physicians who completed surveys, n (%)	10 (12)	13 (21)
QOs contacted, n	81	62
QOs who completed surveys, n (%)	13 (16)	9 (15)
Sites
Sites contacted, n	78	58
Sites with completed surveys, n (%)	15 (19)	13 (22)
Sites with completed survey from both physician and QO, n (%)	9 (12)	9 (16)
Number of practicing physicians, median (IQR)	26 (13.5)	102 (33)
Geographic distribution, n (%)
Northeast	3 (20)	3 (23)
Midwest	2 (13)	5 (38)
South	7 (47)	4 (31)
West	3 (20)	1 (8)
Affiliation, n (%)
NCI	0	11 (85)
NCCN	0	5 (38)
Both NCCN/NCI	0	5 (38)

IQR = interquartile range; NCCN = National Comprehensive Cancer Network; NCI = National Cancer Institute; QO = quality officer.

VBFs

Approximately half (58% [26/45]) of physician and QO respondents indicated that VBFs were used at their sites, with a higher proportion in community cancer centers (78%) compared with academic centers (39%) (Table 2). The most common type of VBF for all community and academic sites combined was the NCCN Evidence Blocks (85% [22/26]) followed by the ASCO Value Framework (31% [8/26]) (Figure 1). The median time to implement a VBF was 6 (IQR = 8) months.

TABLE 2.

Barriers With Implementing a VBF, CCP, and APM

Challenges by care delivery and payment model type, n (%)a	Community cancer centers	Academic cancer centers
VBF	18 total responses	8 total responses
Clinical barriers
Defining the dimensions of value	1 (6)	2 (25)
Weighting the dimensions of value relative to each other	3 (17)	3 (38)
Provider education and acceptance	5 (27)	2 (25)
Incorporation of the patient experience, outcomes, and care quality into the framework	9 (50)	1 (13)
Other clinical barriersb	7 (39)	1 (13)
Administrative barriers
Staff limitations and burden	5 (27)	3 (38)
Access to appropriate and sufficient evidence to support the clinical pathways of the framework	6 (33)	3 (38)
Incorporating cost into the framework	7 (39)	2 (25)
Other administrative barriersb	10 (56)	3 (38)
CCP	20 total responses	14 total responses
Administrative limitations and burden (eg, extra documentation required, manual entry of information to EMRs, or lack of staff)	2 (10)	0 (0)
Institutional development of pathways and consensus on the correct pathway/treatment options	1 (5)	2 (14)
Provider resistance	3 (15)	3 (21)
Difficulty tailoring vendor-developed clinical pathways	4 (20)	1 (7)
Difficulty integrating clinical pathways into EMRs	2 (10)	1 (7)
Difficulty generating performance reports	5 (25)	1 (7)
Substantial cost associated with implementing a clinical care pathway program	3 (15)	6 (43)
Otherb	5 (25)	6 (43)
APM	23 total responses	7 total responses
Difficulty estimating attributable patient population	1 (4)	0 (0)
Difficulty generating clinician buy-in regarding optimizing performance in the model	2 (9)	1 (14)
Financial burden of participating in an ACO or medical home	0 (0)	1 (14)
Lack of institutional support	3 (13)	0 (0)
Operational errors (ie, when resulting in nonpayment of earned bonuses)	0 (0)	0 (0)
Uncertainty concerning performance thresholds for penalties and rewards	3 (13)	0 (0)
Averse to APM downside financial risk	3 (13)	0 (0)
Updates to APM as new therapies are approved	4 (17)	0 (0)
Difficulty obtaining high-quality data for health care services and commodities (ie, specialty drugs)	1 (4)	1 (14)
Innovations in health care services and therapies must be adopted at the site’s own financial risk	6 (26)	2 (29)
Lack of payer engagement and commitment	0 (0)	2 (29)
Otherb	9 (39)	2 (29)

These responses are among responders (physician or quality officer) who had implemented a VBF, CCP, or APM, respectively.

^aPercentages are calculated out of total responses for specific care and payment model by center (eg, VBF; n = 18 for community centers and n = 8 for academic centers).

^bOther open-ended responses are included in Supplementary Exhibit 1.

ACO = accountable care organization; APM = alternative payment model; CCP = clinical care pathway;

EMR = electronic medical record; OCM = Oncology Care Model; VBF = value-based framework.

FIGURE 1.

Distribution and Type of Value-Based Framework Implemented at Cancer Centers

The top motivation for using a VBF was “producing real-world data for providers, payers, and patients,” selected by half of all respondents (50% [13/26]). No other reason was consistently reported. The top clinical barrier for community and academic sites combined when implementing a VBF was “incorporation of the patient experience, outcomes, and care quality into the framework” (38% [10/26]), whereas the top administrative barriers for community and academic sites combined when implementing a VBF were “access to appropriate and sufficient evidence to support the clinical pathways of the framework” (35% [9/26]), and “incorporating cost into the framework” (35% [9/26]) (Table 2). Among the 19 respondents who indicated they were not using a VBF, the most common reason was “lack of accessible patient-specific outcomes” (47% [9/19]).

CCPs

Among respondents at cancer centers with a CCP (76% [34/45]), the most common type was the NCCN clinical practice guidelines (79% [27/34]) (Figure 2). A total of 87% of respondents from community cancer centers used a CCP, compared with 67% from academic cancer centers. The median time to implement a CCP was 6 (IQR = 8) months.

FIGURE 2.

Distribution and Type of Clinical Care Pathway Implemented at Cancer Centers

CCP use was driven by providers (47% [16/34]), institutions (44% [15/34]), and payers (38% [13/34]) (respondents could select more than one). The top 3 motivations for using a CCP was to “improve the quality of care by standardization with the best evidence,” “enhance clinical trial availability,” and “due to payer mandate” (26% [9/34] each). The “substantial cost associated with implementing a clinical care pathway program” was ranked as the greatest barrier (26% [9/34]), followed by “provider resistance” and “difficulty generating performance reports” (18% [6/34]) (Table 2). Among the 11 respondents who indicated their site had not used a CCP and provided a reason, the most common reason was a “lack of consensus on pathway choices” (64% [7/11]).

APMs

Among respondents from cancer centers that had implemented an APM (67% [30/45]), the most frequently implemented APM for community and academic centers combined was the Centers for Medicare & Medicaid Services OCM (87% [26/30]) (Figure 3). All respondents from community cancer centers (23/23) had implemented an APM, compared with 33% (7/22) of academic centers. The median time to implement an APMs was 6 (IQR = 4) months.

FIGURE 3.

Distribution and Type of Alternative Payment Model Implemented at Cancer Centers

The most reported barrier with APM implementation was that “innovations in health care services and therapies must be adopted at the site’s own financial risk” (27% [8/30]) (Table 2). The financial barrier to entry for participating in the APM was rated with a median score of 3 (IQR = 2) (0 = no impact/benefit and 5 = significant impact/benefit). The most common impact of APM on physician practice was “additional nonclinical work” (80% [24/30]). The median number of full-time employees hired per site to perform APM-specific administrative tasks was 5 (IQR = 5.75). The median rating of APM success at reducing costs was 2 (IQR = 2) (0 = no impact/benefit and 5 = significant impact/benefit). The most impactful cost-saving measure reported was “reduced drug spending” (33% [10/30]). When asked who determines the quality measures for an APM, QOs at APM-participating sites most often indicated “payers as a requirement of the APM” (67% [10/15]). Among the 15 respondents who indicated they had not implemented an APM, the most frequently reported reason was “administrative complexity” (53% [8/15]).

Discussion

Our survey revealed that, while the implementation of value-based care delivery and reimbursement models was smooth and helped improve care at some care centers, it was challenging for other centers because of a lack of resources and other internal factors, such as differences in practice size.

Respondents at community cancer centers reported using VBFs more often compared with academic cancer centers. One possible explanation is that the practice setting influences providers’ perceptions of drug value. For example, providers at academic centers may prefer to treat patients with new therapies, which can be tied to revenue streams, whereas providers at community centers balance treatment efficacy with patient-specific factors, such as tolerability, convenience, and quality of life.¹³ Another explanation is that QOs responded more frequently at community cancer centers compared with academic cancer centers. As the successful implementation of VBFs requires project champions, accountable deadlines, and physician-led change management,¹⁴ QOs are often integral to this process and, therefore, are more likely to report implementation. This may have biased the implementation rate reported.

Similarly, CCP implementation was higher at community cancer centers compared with academic cancer centers, likely because of differences in provider perspective and practice. Frois et al reported that community providers experience efficiency and improvements in time management with the availability of pathways,¹³ whereas clinicians at academic centers more often treat patients off-pathway, with treatments based on emerging data not yet incorporated in the pathway.¹⁵ These newer treatments may take longer to become available at community cancer centers. The literature suggests that CCPs are developed collaboratively among physicians, payers, and oncology management programs,^16-18 and our study results are aligned with these findings.

Historically, physician buy-in and satisfaction have been higher when the CCP is provider-driven compared with payer-driven.¹⁹ Several studies have reported that including physicians in the implementation of CCPs leads to greater physician adherence, higher success of implementation, and greater use of CCPs.^17,20,21 Our study found similar rates of payers, physicians, and institutions driving CCP implementation. Overall, the similarity in the rate of involvement reported in our study is consistent with prior publications that emphasize the need of multiple stakeholder involvement in implementing VBFs.^16-18 However, our results are limited to our small sample of cancer centers, physicians, and QOs and may not reflect any one institution’s experience.

In our study of sample institutions, APM implementation was numerically higher in community centers compared with academic centers. Community centers may implement models more easily without having to face the organizational challenges inherent to large academic hospital systems and may rely on the additional revenue due to low margins.²² In addition, community centers may feel additional pressure to prevent losing insurers and patient volume by adapting to new value-based care delivery and reimbursement models. We found OCMs, PCMHs, and bundled payments to be consistently implemented across the participating cancer centers surveyed. Our results align with those from the systematic review by Aviki et al, which found bundled payments and PCMHs to be the most widespread form of APM. This trend may be explained by the structure and application of these APMs.²³ Many patients receive chemotherapy treatments in an outpatient setting²⁴; however, diagnosis-related group bundled payments are primarily applicable in the inpatient setting and do not cover outpatient cancer services. Therefore, it is important to enhance the current payment model and consider including bundled payments for outpatient chemotherapy services. The new EOM expected to begin in July 2023 aims to build upon the previous OCM by making it more applicable to current patient needs and preferences.

Our study captured specific barriers with implementing VBF, CCP, and APM models. “Incorporation of the patient experience, outcomes, and care quality into the framework” was a highly ranked barrier when using a VBF. This is consistent with previous studies reporting that value frameworks are not patient-oriented, which, in contrast with survivorship and supportive care, has been incorporated into new OCM models.^16,25 VBF use is subject to bias because of the practice setting; efficacy and toxicity observations may differ in community settings in which patients tend to be older and sicker, and in academic settings, which are less diverse because of trial use and more intensive hospital-based therapies.^26,27 Future frameworks should be designed to align with the heterogeneity of patient preferences and the care received.²⁸

The top-ranked barrier with implementing a CCP was “substantial cost associated with implementing a CCP.” Prior studies have indicated that costs can be attributed to implementing an electronic medical record capable of using CCPs and the costs of effecting a “culture change” within the sites.^17,19 Culture change entails providers accepting specific CCPs as standardized care tools, which can be challenging because of the burden of adjusting operational workflows and total care delivery improvements.¹⁷ Other changes include additional staff, triage-developed care models, additional metrics, and engagement of consultants, which may not be covered under the Monthly Enhanced Oncology Services payment specific to the OCM or the EOM for the delivery of enhanced services. These challenges were echoed in the “other” free responses captured by our survey, including “culture change often the most difficult” and “no consensus among physicians regarding choice of pathways.” Including physicians in the CCP development, implementation, and monitoring process could help support the culture change needed to use CCPs.^18,20,21 One challenge of CCP use not captured in our results and frequently noted in the literature is the potential negative outcomes of treating patients within a CCP. CCPs do not eliminate prior authorizations or other administrative hurdles and may limit physicians’ treatment options, supportive care measures, and treatments based on patient preferences.^20,29

The top barrier for APM implementation was that “innovations in health care services and therapies must be adopted at the site’s own financial risk.” APMs can delay the adoption of new therapies into their delivery models because centers may be penalized for using new therapies before they are formally adopted. Embracing reimbursements and incentives toward innovative medicines can help overcome these challenges associated with financial risk.^30,31 Therefore, it is important that APMs, and specifically OCMs, incentivize innovation that can improve patient outcomes. This aligns with the recent literature stating that, to increase APM implementation, frameworks need to “broaden the value-based payment portfolio by creating APMs for specialists, and to ensure participating in APMs is more attractive economically for specialists.”³²

For most of the participating centers, “payers as a requirement of the APM” (ie, because of contractual agreements between payers and institutions that implemented APM) determined which quality measures are adopted. These quality measures include progression-free and/or disease-free survival, overall survival, treatment response, toxicity/adverse events, quality of life, adherence, total cost of care, emergency department use, hospitalizations, and end-of-life metrics. However, measures that appear appropriate to payers and were developed to enhance care under OCMs and merit-based incentive payment systems can incur extra care team members and triage teams with 24-hour access for patients and questions. Our study observed that a greater majority of community cancer centers participated in an APM than academic cancer centers. This also aligns with “financial barrier to entry for participating in the APM” being ranked as a moderate difficulty. Building an interoperable electronic health record and information technology support was one of the expensive measures, not only at the implementation stage but also at the maintenance phase, as reported in a previous study.³³ Although not explicitly analyzed in our study, some participants might have experienced similar cost pressure with data integration. Further studies are needed to improve generalizability and evaluate ongoing opportunities and challenges associated with VBFs, CCPs, and APMs.

LIMITATIONS

Although survey reminders were sent out, the response rate of 21% resulted in a small sample size. Response rates varied between physicians and QOs across sites. In addition, although definitions and examples of value-based care models were included in the survey, we cannot be sure that respondents interpreted these models or the associated study questions the same way. In addition, we did not specifically ask about respondents’ presurvey knowledge of value-based care models. There was likely heterogeneity within both physician and QO cohorts despite each having their own survey. Likewise, heterogeneity in model types and cancer centers may have impacted the findings. Inherent to survey research, responders likely had their own bias that could have influenced responses to specific questions. Lastly, respondents were asked about models existing during the period of survey dissemination; therefore, newer models such as the EOM were not assessed. As a result of these limitations, this study should be viewed as hypothesis-generating for future research on motivations and barriers associated with VBFs, CCPs, and APMs.

Conclusions

Measuring improvements in cancer health outcomes is a significant motivator for implementing value-based models. However, heterogeneity in practice size, limited resources, and potential increases in costs can make implementation a challenge. Payers need to be willing to negotiate with cancer centers and providers to implement the payment model that will most benefit their patient population. Future integration of VBFs, CCPs, and APMs will depend on reducing the complexity and burden of implementation.