The Business Behind Oncology Care: Navigating Payers, Parnterships & The Financial Landscape

The Business Behind Oncology Care:
Navigating Payers, Parnterships & The Financial Landscape

Uncertainty has always been one of the biggest challenges in healthcare practice management, but politics in Washington have added a new wrinkle, according to a panel of experts at the 2025 NCODA Oncology Institute.

The annual institute, entitled “Strengthening Partnerships, Enhancing Access,” and attended by more than 225 representatives from 78 industry partners and healthcare practices, was held Aug. 13-14 in Chicago.

Now in its seventh year, the institute provides an opportunity for industry partners to meet face-to-face with practice leaders and healthcare professionals to discuss relevant topics and provide better understanding of their needs and objectives.

The session, “The Business Behind Oncology Care: Navigating Payers, Partnerships & the Financial Landscape,” featured:

James Gilmore, PharmD, Chief Pharmacy and Procurement Officer for the American Oncology Network (AON), a physician-led alliance of community oncology practices that includes more than 300 specialists across more than 20 states. Gilmore, who moderated the presentation, is also an NCODA Executive Council Member.

Wafa Samara, PharmD, Vice President and Chief Pharmacy Officer, City of Hope, a network with 40 clinical practice sites across the nation, including Los Angeles, Orange, Calif., Chicago, Atlanta, and Phoenix.

Jon Hanke, PharmD, Director of Pharmacy and Infusion Services, Cancer Care Specialists of Illinois, a multispecialty practice providing medical, radiation, and hematology services in five full-time centers and 16 rural outreach clinics across Central and Southern Illinois and the St. Louis Metro East area.

“AON’s biggest challenge is establishing long- and short-term strategies to deal with new rules and regulations like the Inflation Reduction Act, Most Favored Nation drug pricing model and tariffs.” – James Gilmore, Chief Pharmacy & Procurement Officer, AON

Gilmore opened the presentation, noting that AON’s biggest challenge is establishing long- and short-term strategies to deal with new rules and regulations like the Inflation Reduction Act, Most Favored Nation drug pricing model and tariffs.

“There’s uncertainty on how the rules are going to be rolled out and what the impacts are going to be,” Gilmore said.

Samara agreed, noting, “We meet every week just to discuss what’s going on with politics.

“Every day there is a new story, every day there is a new direction. The impact is uncertainty, and when you have uncertainty, people like us … have to pause and think, ‘Do we approve travel for everybody? Do we buy the technology that we have planned to buy now?’ We need to be careful about expenses because we’re trying to continue to provide care. At the end of the day, it’s going to impact patients, but we don’t know how.”

Politics aside, uncertainty in any circumstance is a challenge for healthcare planning, Hanke said, citing payers changing their rules midstream as a prime example.

“A few weeks ago, our prior authorization department messaged me saying the provider said this patient has been on this medication, but the insurance has changed and they won’t cover it anymore,” Hanke said, adding that the practice would have to switch to another product, a product that it knew it was underwater on.

So, we have two options: One, fight it, put in a prior authorization and continue to work with insurance, and maybe delay patient care, which is never a good thing,” he explained. “Or, let’s switch, we realize we’ll be underwater in this product but reassess at a later date. Because at the end of the day, patient care comes first.”

Planning for wastage is another big issue, he said.

“We service outside clinics throughout the week. Orders come in the night before. All of the setup work for the chemo is done then and sent out to all of the sites. Now, a patient might be sick that day, might not get a ride that day or labs might come back abnormal that day, so we can’t treat them. So, we scramble, canceling the treatment. More than likely, we’re going to waste the order. Trying to plan for that is very difficult, especially now with the (current political) uncertainty.”

The panel addressed a number of other issues as well.

WHAT CAN MANUFACTURERS DO TO HELP US OVERCOME SOME OF THESE CHALLENGES?

WS: “What we want to do is the same thing that manufacturers and pharma want to do: make sure that we are providing the best care to the patients. And make sure every patient has access to the right drug at the right place regardless of where they live at the right time.”

Samara recommended that manufacturers meet with practices to discuss such topics as manufacturer assistance programs and fair distribution of new innovative drugs to all pharmacies.

“Let’s face it: We want to use your drugs; you want us to use your drugs. What’s the contract price? What’s the rebate? Take it a step further. Be proactive. Be specific to my practice, to everyone’s practice. That transparency can help us take it a step further and make decisions for each patient.” – Jon Hanke, PharmD, Director or Pharmacy and Infusion Services, Cancer Care Specialists of Illinois

JH: “Let’s face it: We want to use your drugs; you want us to use your drugs. What’s the contract price? What’s the rebate? Take it a step further. Be proactive. Be specific to my practice, to everyone’s practice. Our drug is covered by Blue Cross Blue Shield of Illinois, but it’s not going to be covered by CIGNA. That transparency can help us take it a step further and make decisions for each patient.

“The other thing with the waste… some manufacturers have product replacement programs, some don’t. Any-time we have waste, a missed treatment or something to that effect, we’ll try to log in and contact the proper authorities within the manufacturer to get replacement. Some get approved, some get denied. What I would love to see is making it simpler for the practice across the board, a universal product replacement program where we all work together on a broader level. That would be a huge help for the practice moving forward.”

WHERE DO YOU STAND ON ALTERNATIVE PAYMENT MODELS & VALUE-BASED CARE?

JG: “About 20% of our oncology patient population is in some type of value-based care (VBC) arrangement. We want to have the highest level of care across the board. But it is challenging balancing the maximum Net Collection Rate with trying to provide quality care but doing it at a lower cost.

“In the Alternative Payment Plan perspective, we’re working with payers trying to match our needs with their needs to create win-win situations where we get steerage into the practice and preferential treatment at a lower cost. We try to avoid the burdens of prior authorizations. In exchange for that, we provide a higher level of care and hit certain quality metrics in providing care a certain way.”

JH: “We mostly navigate through the Merit-based Incentive Payment System that’s overseen by our chief operating officer, our nursing director. We value that because we feel we are able to gauge our strengths with the patient care.”

WS: “The problem with VBC is that there is a lot of work that needs to happen in the background. There are a lot of requirements. We were in conversation with one big pharma about one big value-based agreement that we’ve been trying to put together. It came to my desk for review. Just looking at it, it’s a lot of work, it’s a lot of data mining. Is the juice worth the squeeze? Of course it is. We can show that we have superior outcomes, but then we are bogged down with the data, the paperwork and all that stuff, so I hope there is going to be a way to make it easier for us.

“We’re a big health system, but I worry about the small, medically integrated practices that don’t have the bandwidth or the support, financials or the infrastructure to participate in VBC. But everybody should. Maybe we could come to an agreement about how we pull the data, how we support data mining … streamlined and built within the Electronic Health Record.”

HOW DO YOU MAKE DECISIONS ON DRUGS & FORMULARIES?

JG: We have a Pharmacy and Therapeu-tics (P&T) meeting every two weeks. Stakeholders from across the enterprise that participate. It’s a big investment in cost for our organization because we have close to 40 people that spend an hour and a half every two weeks. We make decisions on which drugs we are going to use and how we are going to use them We make those decisions based on efficacy, tolerability and value, in that order. Once we make decisions, we have a lot of different channels that we communicate that information whether it’s weekly emails, text blasts … we have different tools that the providers have access to and we have clinical pharmacists to help pull through on those initiatives.

“We’ve created adherence tools so we can go about and evaluate adherence, how our providers and officers are adhering relative to our guidance. We have evolved to a situation now because of the payer landscape and VBC where we almost have payer-based formularies. It depends on what the payer situation is for the patient and the approach to treatment.”

JH: “We have a collaborative effort from the top, from our president, to the providers, to all the departments. The doctor sends a message to the pharmacy. My pharmacists build all treatment plans following NCCN Guidelines. They send a message to prior authorization, they make sure it’s covered, then it goes back to the doctor and they review it.”

“As far as for formularies, a select pharmacy team meets monthly with certain providers to discuss changes in the treatment plan and issues as far as reactions, and with all of the facilities on how they might be making changes. For formulary, we look one to two quarters ahead.”

WS: “I meet monthly with our national P&T committee. Our P&T is chaired by their system’s chief medical officer, one of our clinical pharmacists. Decisions are made at that level for what kind of formulary we want to adopt and change based on the new clinical recommendations. And then it goes down to each market. Each market has their own P&T. We’ll say we want to adopt this and then each P&T will take that decision and make it work in their market.

“Our formulary management is a team sport. We want everybody on the care team to be involved in the decisions. We think we’ve been very successful. I would say we’re not 100% on one formulary … but we’re very close to being standardized.

“We want to make sure we don’t have denials, so we implemented a pharmacy-run medication denials service, which has been amazing. Implemented in Southern California, we now want to bring it to our other states. It’s been very successful in mitigating denials.”

WHEN YOU GET YOUR MEDICARE REIMBURSEMENT RATE, IF PAYERS FOLLOW, DO YOU MOVE STRAIGHT WITH THE DRUG OR WAIT UNTIL MEDICARE RULES ON POLICY?

JG: “We have the ability to use drugs that don’t have permanent billing codes or established Medicare allowables, we just have to balance that with the desire to use that product. So, if it’s a new innovative product and we have a lot of patients and there’s a big need for it, and if it’s the right thing to do for the patients, in our environment we will do that. But if it’s just another “me-too” drug with no real clinical advantage, it might make more sense to not have that risk for a couple of quarters until we do have established billing codes.”

JH: “Yes, but several boxes have to be checked: the value has to be there, the efficacy, the trials, everything has to be there as far as within our practice. We’ll look at it and if it’s all there we’ll utilize it as far as our Medicare supplement patients. We’ll use a temporary J code. Once it gets an established J code, we’ll use it for all the payers.”

DO YOU PREFER 12-MONTH OR QUARTERLY CONTRACTS?

JG: “We like a consistent view of what value proposition is, we’re always looking for stable fixed baselines. It would be great to have long-term contracts. But we also have to have the flexibility to adjust throughout that term if, for instance, government policy changes.”

WS: “I would like to have long-term contracts but we have to be nimble. We need to be working together if things change.”