Trends Shaping the Business of Oncology in the Year Ahead: Part 2

Host Gordon Kuntz and guest Bryan Loy, MD, MBA, discuss key trends shaping oncology care in 2025, including provider and payer consolidation, the shift to value-based care, and evolving approaches to patient access and data-driven care coordination.

Gordon Kuntz: Welcome to Oncology Innovations, a Journal of Clinical Pathways podcast, focusing on candid discussions with innovators dedicated to enhancing quality, value, and the role of clinical pathways in the evolving cancer care ecosystem. I'm your host, Gordon Kuntz. I am a consultant with 20 years of experience in oncology clinical pathways and the business of oncology.

I've worked with oncology practices, pharma, payers, group purchasing organizations (GPOs), and pathway developers—basically every aspect of the oncology ecosystem. I'm also a member of the Journal of Clinical Pathways editorial board, as is our guest today. Today's podcast is a special one. We are here today with Bryan Loy, medical director at Humana, and we'll be talking about some key trends impacting oncology that we see for 2025.

I've known Bryan for many years. He leads Humana's oncology initiatives and has been a longtime innovator in the cancer space. As Bryan and I prepared for this episode, we landed on 3 key trends that will shape the business of oncology in the next 12 months: consolidation among providers—but also payer consolidation—the ongoing shift from volume to value in cancer care payment, and patient access restrictions.

That was actually another question that I had for you. Speaking from a payer standpoint—not specifically about Humana necessarily, but from a general payer standpoint—as the financial risk shifts to practices and they're responsible for not only delivering the care but also for the cost of care, it may require a capitation or sub-cap kind of arrangement. How do you expect payer policies to reflect that? Because it seems discordant to me that a payer would have a prior authorization process and make the practice financially responsible. It's like, “Let me just do my thing. I'll take care of it; don't you worry about it.”

It seems like if I were a practice, that would be what I would be trying to communicate. I don't know if you're seeing that as a future state or what you might think is going to happen there.

Bryan Loy, MD, MBA: Certainly, that concern enters the conversations and the narratives we've had with some of the groups: relieve us of the administrative burden. The creative minds will then come together to figure out—so what is the challenge? The challenge still remains. We have customers, oncology care is expensive, and there are trends that aren't always explainable that are not standardized. When you do an outlier analysis, you start to have to ask the question: Why is care more expensive over here for what appears to be the same population of a subsegment of cancer?

The accountability will shift, in my view, to what we talked about a little bit earlier: ensuring members get good care, timely care, etc. The measurement system will be a little bit different, rather than saying, "Is this reasonable and necessary?" to, "Are we getting good care in a timely fashion, and are we getting the type of care [needed]?" I think those can be measured in different ways and allow for the reengineering of some of those processes that are in place. Much of that could better be dealt with, in some instances, by having conversations through data analysis and sitting down with the practice, not in the heat of the moment when there's a requested service but looking for pattern recognition.

The one thing I've learned in this industry is that there's this idea that payers are sitting on a lot of information, and we are. But to the extent that we can make that meaningful and digestible information for a practice requires some really deep analysis and thoughtfulness. When you start to look at variations, even within a single practice, you start to bring insights that even the practice leaders are not aware of. As you acquire practices, I think there's an enormous opportunity through data analytics to cross-pollinate across existing practices as well as newly acquired practices, and for them to benefit from it as well.

If you can demonstrate that to a payer or if you demonstrate that to other risk-bearing entities, like referring groups that are also taking on risk, I think that's what the next phase is going to start to look like. You've got consolidation. You've got these opportunities. Now show me over a period of time where there's been measurable, incremental improvement in some metric that's important to us or the patients or both.

Kuntz: If you've got financial accountability being moved to the practice, what I'm hearing you say is the payers’ job in this particular realm might shift to more of a quality oversight to ensure uniformity across the network. There may be some reimbursement tiering that goes along with that, or program tiering, but also timeliness of access, reducing wait times, and improving quality. The practice has to cooperate in that because they have data that you would never see from a claims standpoint that would help to reinforce that.

Dr Loy: I'm quite encouraged by some of the systems that practices have shared in terms of the type of data that they’re collecting, and they're willing to at least share the processes. I think that sharing that information will not only help the experience of delivery but also will help to get a deeper understanding of the member.

We don't know, from the payer end, whether someone is experiencing financial toxicity, transportation issues, or social determinants of health (SDOHs). What we do know is that, from time to time, we see they started down a treatment journey and then they stopped. Did they get sick? Did they run out of money? Did they lose their ride? Did they just give up? We don't know. The practices have that opportunity to help take the next step. The payers have an opportunity to support them in that journey. That's pretty exciting to me, the prospect of being able to improve member experience.

Kuntz: Before we move off this topic, I want to explore one additional aspect. I want to piggyback on what you just said to get there. In my conversations with practices, there are a few on the leading end of this business that are basically saying, "We know we can make margin on drugs. We're going to leave that aside. What we really want to focus on is the total cost of care. A significant portion—maybe it's only 30%, but we see that growing—of our patients are going to be covered under value-based care arrangements where we're going to be financially responsible. We have to understand what the total cost of care is from a pharma manufacturer, not just the cost of the drug." They can't really control the cost of the drug, but they want to understand what this total picture looks like. I'm trying to think about what the changing attitudes on the part of practices are.

That's one aspect of it, but what you just mentioned, I think, would form another dimension: sharing with the payers what additional data you're collecting that might be relevant. What is that patient experience? I don't think we've focused nearly enough on that aspect of it in the total picture because it's easy to get reduced down to, “What's the cost? Am I on your pathway—yes or no?” and then move on to the next topic. But I think there's this whole element of social determinants that Centers for Medicare & Medicaid Services (CMS) has done a good job of bringing to the forefront, which ties into a bigger picture of, “Maybe I don't have the traditional limitations of social determinants, but maybe I have other issues that are inhibiting me from receiving care.”

Dr Loy: One of those issues—and I know you and I have talked about this more than a little—is in looking at new drugs to market, there are choices and there are guidelines that allow for multiple choices. I think aligning care with patient values, especially in the senior population, and trying to tip the scales toward making sure that the care that's delivered is really in the interest of what patients want—whether it be curative, quality of life, or extending their survival in a meaningful way—all those things need to get out on the table to try to figure out how to optimize that as best we can.

What I think an additional frontier that's going to be out there is we continue to see drugs come to market through either the accelerated approval process—which provides good access—asking the questions: does this apply to these patient populations that we're serving relative to the other alternatives, what are the things that best align with the members values, and are we having those conversations?

So, I think there are a lot of things that can take place in a provider-patient relationship within a value-based care agreement that really aren't within the tools or the scope of what the payers have traditionally been able to do. That too provides opportunity that we simply haven't had. It's been talked about. I think we're now entering an era where we've taken things from the hypothetical of what value-based care could look like and it feels to me like we're entering an era where we're starting to mature that thinking into a way that we can look forward to implementing new opportunities.

Kuntz: We touched on patient access restrictions—things like prior authorization and formularies and whatnot—in the last conversation about how we expect that maybe those will be lifted. But I keep seeing articles about providers complaining about having more and more of these prior authorizations to do. It's taking more of their time, there's more scrutiny and more denials, and then they have to appeal. Eventually they get what they were asking for, but the road seems more difficult.

Without getting into what Humana is or isn't doing and your policies, in general, in the payer space, is that something you're seeing, or is that a bit of smoke and mirrors?

Dr Loy: I won't speak for the entire industry because there's a lot in what you said, but I would say obviously, everybody has a customer. If you're in Medicare, CMS is your customer. If you're an employer group space, the employer satisfaction is your customer. If you're in other areas of the business that are governed by state, you've got other stakeholders that are putting guardrails around how you conduct business.

At the end of the day, I would tell you that I think that we're entering an era where we shouldn't be asking questions that we can already know the answer to. We should be figuring out ways to get out of the way if we all agree that this is good quality care. We should be sharing with each other what's next so we can agree on things in the future tense, rather than trying to react to the present tense. With all of that in mind, I'm starting to see the evolution of platforms that are being able to gather that type of information to try to help maintain the accountability that folks are looking for and reduce the administrative restrictions.

For example, let me make that real for you. If you knew somebody was getting, either through claims or through some other health plan mechanism, a CT scan, you would say, "Oh, okay, if they're on treatment, somebody is assessing whether this drug is working or not, or if a symptom has cropped up someplace, there may be something going on in this patient's life." Being able to have even that piece of information could help someone to figure out whether, "Hey, I know to go ask for this and get the answer to whether or not something needs to be continued or not and make any sort of administrative burden minimal or nonexistent.” I think those opportunities are starting to surface more and more.

Kuntz: We've heard a lot about artificial intelligence (AI) being used in denials for care, but what I'm hearing you say is that if AI were used as more of a contextualization opportunity to say, "Here is what's likely happening based on the fact that you're in the middle of a course of treatment, you're asking for an MRI, a CT scan, or some diagnostic test that may not be strictly called for in some protocol, but it's not unreasonable that it would be used. People don't do these things for fun. Nobody's doing it just because. If there's a logical explanation, it does seem reasonable that there would be essentially a much lower bar for scrutiny." Again, you look at things retrospectively and say, "You did eight of them. Maybe we don't do eight." Something like that, or you put a limit on it. I just feel like we could be a lot more sophisticated about that sort of thing.

Dr Loy: I understand there's an attraction towards AI. But I also understand that there are platforms in place that could help answer many of the questions that we're talking about simply by extracting from already known data sources, like claims payment or like other prior authorization processes, etc. Bringing those to one central platform to be able to say, "This is the only piece of missing information," and seeking that rather than putting people through the same processes repetitively—I think there are some small steps that could be taken even today while folks are still figuring out the acceptable applications of AI. I think that there is work that could be done now.

Kuntz: One of the things that—and again, I've tried throughout my career to move this all forward and it's hard, but I am seeing a little bit of this—is for those practices that are following a nationally accepted clinical pathway, if that's the case, and you said earlier we shouldn't be asking for things we already know, if they've gone through and they're on pathway or their historical average is 82% on pathway, it almost seems like the prior authorization is redundant.

If you're checking for medical necessity, that's what the pathway did. It told you this was medically necessary and, frankly, optimal and now we're going to have some algorithm check that for us again? First of all, what are your thoughts on that? Second of all, is that something that's doable, because I've heard in the past, “It's a systems problem and there's only so much we can do.” Theoretically, should it happen? Second of all, do you think that's a reasonable place to move towards?

Dr Loy: I think it's a reasonable place to move toward. The incremental steps that I've seen in my career have gone from facts and drug-by-drug assessment to let's look at regimens and let's get things that we all agree are quality of care that we should get out of the way for, make those as easy as possible to get assurance that you're going to get payment.

Those are things that have taken place that I think we all can take some pride in because they didn't come from someone sitting in a room someplace saying, "Here's a piece of software.” They came through some careful collaboration, iteration, refinement, and payers talking with providers to figure out what is it that we can do to make the existing painful processes timely and provide reasonable assurance of payment.

But I think what you're talking about is, why do you even need to figure that out at all? If there's a way for us to get that notification without asking for information, or with a simple click of a button, and take my word for it, and you can audit me if you don't trust me, I think we're pretty close to much of that. But I would also say to you, I think the “Holy Grail,” at least that folks talked about 5 years ago was, let's figure out bidirectional communication through your electronic health records (EHR) with the plan. If we need to go look for a piece of information, or you've submitted something that says, "This is on a pathway. It's recognized. There shouldn't be any question," and there was something that clear that became the connection point to be able to validate any of that. But that hasn't happened yet.

There have been a few isolated cases where that has happened, but building those pipe works for every payer with every practice and maintaining all the guardrail around patient confidentiality and different system interface is a very expensive and laborious task. I don't know how that gets accelerated and facilitated. I think that opportunity still exists out here. I don't see it completely going away. But to get to that, there was a notion that these platforms on the provider side would all be the same—and they're not—and that all the payers will be the same—and they're not.

I don't know that we anticipated that or, let me say it differently, I'm not sure that we fully appreciated that. It seems so simple at the very beginning, and it seems so solvable, and I think it is, but it takes a lot of smart people to build those interfaces.

Kuntz: I'll tell you, I could do this all day. As with all of our conversations, I always feel like it's too short, but I want to thank you for your time today.

This is going to wrap up our episode of Oncology Innovations, a Journal of Clinical Pathways podcast. A big thank you, Bryan, for sharing your insights on the key trends shaping oncology in 2025, from consolidation and the shift to value-based care, to the evolving landscape of patient access restrictions. As always, our goal is to bring you candid conversations with industry leaders, like Bryan, who are driving innovation and shaping the future of oncology care.

If you enjoyed the discussion, be sure to subscribe, leave a review, and share this episode with your colleagues. For more insights on oncology clinical pathways, value-based care, and payer dynamics, visit the Journal of Clinical Pathways and follow Oncology Innovations for future episodes. I'm Gordon Kuntz. Thanks for listening. Until next time, stay informed, stay engaged, and keep driving innovation in oncology care.