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Introduction and Episode Overview

[00:00:00] Stacey Richter: Episode 442, "A Short Rumination on Saving Money, Except Not Saving Money. Oncology Side Effect Management as a Case Study,” With Andreas Mang. 

American Healthcare Entrepreneurs and Executives You Want To Know, Talking. 

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This week, I'm gonna play an outtake, I guess it could be called, from the show with Andreas Mang from Blackstone that we wound up cutting for reasons of time and topic, but it's been on my mind ever since. So here's this clip and then I'm gonna invite you to partake in my ruminations, because they hit the trifecta of employers and taxpayers and patients themselves getting taken for a ride from a cost perspective, while at the same time, patients are harmed. And the whole thing is so short sighted. 

Anyway, here's the clip that started my downward spiral into, what's the medical mental health term when you can't stop rehashing something? Here's the clip. 

Clip from Andreas Mang on Chemotherapy and Dehydration

[00:01:12] Andreas Mang: So what is the number one, I gave it to you already, but I'll just repeat it. Number one reason for readmissions, I think universally, if you looked at any health plan and readmissions are bad, right?

Bad quality and really expensive because something you went in for and came out, you're back in and it's probably pretty bad. But the number one root cause of readmissions is dehydration associated with chemotherapy. Think how silly that is. Dehydration should not be the reason. So, you're getting chemo, you're feeling sick, you can't keep down fluids, you're vomiting, and so, you end up back in the hospital.

Well, guess what? There's medications for that. Real simple, easy to take meds that's the nausea, so you can keep down fluids so you don't get dehydrated. So, what have we done? In our world, on our platform, and health plans have tried to do this too, and they've done a reasonable job with their nurses and care managers, but like, in our world, we have an oncology trained nurse that is on your hip, through your treatment, as you go from Dr. Jones to Dr. Richter to Dr. Mang to doc, right? And none of us are talking to each other. And so, but, but you have Nurse Sally on your hip talking to you whenever you want. At a minimum, they're checking in with you, maybe it's daily, during different bouts of treatment.

Hey, how you feeling today, Andreas? I can't keep down my, I'm nauseous, I'm not drinking anything. Oh, let me call your doctor, let me get you a med, let's get you that script that's gonna suppress your nausea, be able to keep down fluids, you won't end up back in the hospital. Pretty simple solution, right? 

The Importance of Managing Oncology Side Effects

[00:02:42] Stacey Richter: So that was Andreas Mang, and go back and listen to the whole episode 419 about the whole way health benefits have become financialized in ways that CFOs and CEOs and boards of directors may want to be aware of. It's not just people downstairs or in the warehouse who get cancer, after all. 

But also for all of the reasons which Andreas covers really well in that earlier episode. Andreas, by the way, is senior managing director at Blackstone and CEO equity healthcare at Blackstone.

Let's get this party started with a tweet from Mark Lewis, MD. Mark Lewis is an oncologist and he tweeted, "Dear insurance companies, antinausea medications signify one of the greatest advances in oncology. Chemotherapy has to be effective, yes, but it also has to be tolerable too. My patients risk getting sick every cycle. Please help me help them. It's never been more important."

Then here's what Celena Latham wrote in response to this Mark Lewis, MD tweet. And if you go hunting around on Twitter or X or Facebook, you can find literally thousands of others saying the same basic thing.

Celena writes, "I fight with my insurance company all the time. They are happy to pay for my $10k a month chemo drug. But the $10 a day nausea med is restricted. I am only allowed a 21 day supply at a time. The supply given is not enough."

I was keeping all of this in the back of my mind when in May, I was at the Memorial Sloan Kettering, MSK Direct Day. And I heard a talk from Dr. Jun Mao that puts a lot of this in context. Dr. Mao presented a slide, link in the show notes. Turns out, study show, you can save one million dollars per 100 cancer patients over three months by doing what's called integrative oncology. And a big part of that, or a part of that, is managing treatment side effects like nausea and vomiting and thus keeping patients out of the ER for dehydration.

Thanks by the way very much to Greg Greene and Emily Kauff for inviting me to that event it was great. 

Now, is this whole, hey lets manage oncology side effects line of thinking some sort of breaking science? Let me refer you to a show I did with Dr. Ethan Basch in 2017. That was seven years ago. It is entitled "Major Improvements in Oncology Outcomes When Patients Self Report Symptoms".

In that interview, you can hear Dr. Basch talk about how he and his colleagues found that by doing things like managing side effects like nausea, patient survival time improved about five months. 

Those drugs that cost hundreds of thousands of dollars that are coming out, those immunology agents, many of them do not increase survival time this long.

So, not only are we talking about saving money here by managing side effects, but wait, there's more. Survival time improves by an astounding amount, really, comparatively. We also had on the show in 2019, Dr. Nadine Jackson McCleary from Dana Farber and Harvard Medical School. She was talking about this. Oh, and also Glenn Sabin from FON Consulting in episode 233.

So this is not news is the bottom line. And all of these kinds of facts and figures have been running through my mind while I've been ruminating over that outtake with Andreas Mang that I just played. Now let me get into the kind of the whys and the wherefores that I just really can't stop rehashing.

Ruminations on PBMs and Total Cost of Care

[00:06:06] Stacey Richter: First off, let's just keep in mind, PBMs often have but one incentive, maybe but one job, depending on who you talk to and from where. And that one job is to lower drug costs, at least for themselves. Right now, some PBM is busy regaling their employer client about how much money they saved. But let's just say the quiet part out loud.

In the oncology part of that spreadsheet, if the PBM restricts access to nausea meds, the employer will have lower PBM costs and higher medical costs. Let's say the nausea med costs $5 a month, or even $1,430 a month, which is the cost for a four-drug nausea and vomiting prophylaxis regimen, as per the NIH study I just read.

So, here's me comparing that 5 to 1430 a month to the aforementioned million dollars saved on a hundred cancer patients over three months stat that's $3300 a month per patient. So, you know, PBM saves five bucks, a few hundred bucks, maybe even fifteen hundred beans on the high end.

And we spend $3300 on medical costs. In this case, the downstream impact is also like, not going to take years to accrue, so everybody wonders if they're footing the bill for Medicare or somebody else who's going to receive that downstream cost savings. No, this is pretty immediate balloon squeezing, I would say. Right? 

Cancer patient has untreated nausea and vomiting. Cancer patient winds up in the ER. Dan Mendelson talked about this in episode 435, by the way. He said extremely crisply, I would add, “plan sponsors gotta look at the total cost of care, ie, PBM, pharmacy spend, and medical spend together.” 

So that's my first point to ponder, just the vital nature of aggregating PBM and medical data into a database of total costs. Which means that anybody trying to do population health can do their own math as opposed to relying on vendors to calculate their own in air quotes savings, which anyone who has ever hired a point solution knows has the potential to not go well because it could enable somebody to in air quotes save money in one place and cost a whole lot of money elsewhere. 

Cora Opsahl also talks along these lines very compellingly in episode 372. She says if your data analyst can't find savings opportunities, and by the way, data analysts looking at the full data set, such as the nausea example, but if they can't find savings equivalent to their salary, then you have the wrong analyst, not a superior health plan.

Al Lewis talked about this also in great detail in episode 331. All these links are in the show notes, by the way. And furthermore, if we need one, I was also talking to Shawn Gremminger the other day from the National Alliance and he said this exact same thing. Aggregate your data so you can see the total cost of care.

Do your own math. And look, I think everybody is saying this exact same thing because at least one goal is to spend less overall, not spend less on your way to spending more. Because that doesn't count. This matters if you're actually going to succeed in cutting out waste and spend. But I might also scramble out on a limb and suggest that in probably a lot of instances, if you identify something that costs less in the short term, but drives up the total cost of care, especially when that total cost of care is going up in a relatively short-term period.

And if you know this and correct it by just spending a little bit more going in so that you spend less overall, you probably just fixed what is very likely a problem for patients in patient health. Feel free to agree or disagree on that point, but I bet I'm right. 

That's my first rumination. Just how this nausea from chemo is a great example of the why with you got to know the total cost of care.

Value-Based Drug Purchasing and Its Implications

[00:09:50] Stacey Richter: My second rumination is just the whole thing with value-based drug purchasing. Or even medical purchasing, as opposed to cost containment efforts that could spike costs elsewhere and or cause a lot of presenteeism and absenteeism while the PBM vendor or maybe even like the ASO or some provider organization gets a prize for controlling trend in the very short term, probably.

Nina Lathia talks about this in episode 426 and also Barbara Wachsman. So second point, having a value mindset when purchasing is a thing. Look, I'm just going to state for the record that Blackstone knows how money works. And they have calculated, I would trust, that it is cheaper, at least for their populations, it is cheaper to manage chemo side effects than to not manage them.

Or even worse, to restrict access to needed medications. 

Challenges in Oncology Side Effect Management

[00:10:43] Stacey Richter: Which leads me to the third thing I'm thinking about as I consider how it can be that chemo side effects like nausea can possibly, in this day and age, go untreated or undertreated or undermanaged. I was talking to Dr. John Lee the other day, and he was talking about getting blood pressure readings from heart failure patients.

But trust me, I will bring this back to oncology patients left to their own devices in just one sec. So it turns out, The best way to get blood pressure readings from heart failure patients at home to make sure they don't wind up in the ER and readmit it is have a nurse call them at home and ask them what their blood pressure is.

Works actually a lot better than any fancy stuff you might have been thinking of, but most provider organizations won't do any dialing for blood pressure readings because they don't get paid for it. And I'm pointing fingers all over the place and nowhere right now, but consider this blood pressure reading case study in the realm of managing oncology side effects like nausea.

For any given patient population, who is doing this side effect management? Does anyone know? Is anyone getting paid for it? And if no one is getting paid directly, then which hospitals are taking dollars they're earning from buy and bill, which could be four to six times the cost of some of these oncology drugs, ie, a lot of money, lots of zeros. Listen to episode 370 with Erik Davis and Autumn Yongchu for just how many zeros and how they're doing it. But which oncology centers are taking these tens of thousands of dollars earned on the backs of buy and bill, and using this money to run integrative oncology programs or manage side effects, like nausea.

A few do, don't get me wrong, many do not. Or they don't do nearly the stuff required as per the studies which demonstrate actual patient results. Like you have to be collecting PROMs, patient reported outcome measures, etc. 

Dr. Tom Lee talks about this also in an upcoming show, this whole idea of having a value mindset and considering what good for patients looks like and then figuring out within current payment models how to make this happen so that patients get better care.

But also, and this can't be understated, doctors and clinicians are happier and not morally fatigued by an obvious failure to, you know, not have patients spend the last three nights curled up on a towel under their toilet before heading to the ER to get hooked up to an IV. So that's my point three rumination.

Fee-for-Service Model and Its Limitations

[00:13:07] Stacey Richter: Fee for service, FFS, does not pay or pay adequately for stuff like making sure chemo patients, who a lot of the time will have side effects that can be costly, FFS does not pay to ensure they are proactively well managed. What FFS will pay for is waiting for the patients to fall off the cliff instead of preventing them from falling, as Darrell Moon often says.

I guess this is the story of FFS, but this one, this whole nausea case study pretty quickly has accruing costs financially and also from an employee emotional and physical impact standpoint. So back to that Andreas Mang quote, it seems like he and his team have concluded there could be a ton of variability in care.

Providers may or may not have a value mindset and sufficient operational chops, and may or may not choose to use dollars they earn off drugs or other services to do meaningful things that they may or may not get compensated for. This feels like something payers should be cognizant of because most employers don't have resources Blackstone has to stand up their own nurse program when providers fail here.

And there also could be probably a pretty big equity consideration in the mix at the same time. But just point three, fee for service doesn't pay for stuff like this. It's going to be up to a provider to choose to do it or not to do it. And all of that is a consideration for employers. Here's my last point on pondering number four.

Business Case for Side Effect Management

[00:14:34] Stacey Richter: And it also concerns what's going on in or about oncology centers themselves. I thought of this while moderating a panel at the recent Thinc Conference last month, and on this panel was Buck Poropatich from Lyft Health. He said something fascinating. He said there's two business cases for a health system to pay for transportation.

And again, I'm going to talk about transportation for a sec, but this is relevant to our oncology side effect management case study here. So two transportation case studies or two transportation business models. One is the value-based care arrangement business model, but let's not talk about that one because it's very obvious to most how dealing with social drivers of health is key when you are getting capitated payments to manage patient populations when you are in fact responsible for downstream costs of care so let's just set aside the value-based care business model for transportation. 

The business case I was fascinated by, though, is the fee for service business case for a hospital or provider organization to pay for transportation. It's because no shows are really expensive from a lost revenue perspective, and a lot of times the reason patients no show is because they do not have transportation.

Or another use case is getting a patient discharged promptly to turn over a bed when the patient can't get a ride home. If a health system is savvy enough to do the math, it might wind up being a profitable endeavor to pay for transportation for patients who need it. I started pondering this in the context of oncology center slash provider organizations doing side effect management properly.

Is there an FFS, fee for service slash buy in bill, "why", to stand up some of the care flows and do the outreaches and apps really well that are all necessary to do side effect management right? Is there a business case to do all of this in a fee for service environment? 

Short answer, I don't know, but I keep seeing studies showing that when side effects aren't managed, courses of therapy are shortened to the patient's detriment, we're talking now in this use case, or doses are lowered or patients die prematurely. You would think that if someone at an oncology center was able to, and did, calculate the lost revenue from any or all of these downstream impacts of poor side effect management that's similar to the transportation use case, it makes sense to really, for real, do integrative oncology and side effect management properly and proactively. 

See the show notes for these four ruminations all written out, but they are number one, the importance of the total cost of care and knowing what it is for financial and also health of members slash patients slash population reasons. 

Number two, value based drug or having a value mindset for purchasing almost anything may be cheaper than a cost containment mindset. 

Number three, some oncology centers are doing integrative oncology and side effect management for real and programmatically and others are not. Meanwhile, where are the payers in all of this and how are they thinking about preventing avoidable dehydration readmissions? Question mark. While an employer, it does feel important to at least be aware that this is going on and ask questions about it of payers and providers, etc. 

And then number four point rumination is, I speculate there's a fee for service business model for oncology centers to do side effect management, but they have to have a bead on their own data to know whether or not this is true.

Conclusion and Call to Action

[00:18:12] Stacey Richter: So maybe my ruminations are sparking some ruminations of your own. My name is Stacey Richter. This podcast is sponsored by Aventria Health Group. 

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