A modified Delphi panel of eight value-based payment (VBP) experts identified core features and barriers to effective oncology payment models and offered priorities for future design.
The panel met Dec. 18, 2024, in Dallas and completed two survey rounds with an in-person discussion. Participants evaluated the importance and feasibility of VBP elements, ranked commonly used payment approaches, and assessed benefits and challenges using Likert scales and group deliberation.
Panelists reached consensus that patient-centered care, robust risk adjustment that accounts for clinical complexity and social determinants of health, and oncology-specific outcome measures are essential to effective VBP models. They emphasized shared decision-making, electronic patient-reported outcomes as a tool (not a standalone goal), and the need to integrate equity and symptom management into payment design.
Commonly used models include fee-for-service, pay-for-performance, Oncology Care Model/Enhancing Oncology Model (OCM/EOM), and single-sided shared savings. Pay-for-performance and enhanced monthly payments were viewed as feasible and widely adopted because they are relatively easy to implement and support care coordination. However, panelists criticized these models for relying on outdated or process-focused metrics, imposing significant administrative burdens, and providing payments that often do not cover the full cost of nonbillable but essential services such as care navigation and psychosocial support.
Higher-impact models—single- and dual-sided risk arrangements, prospective payment/capitation, cost-benchmarking, and longitudinal cost-containment approaches—were seen as promising for driving accountability and cost control but are harder to implement. Key obstacles include inadequate risk stratification, potential to penalize practices serving complex or underserved populations, high reconciliation and reporting demands, and reluctance among smaller or rural practices to assume financial downside risk.
Panelists identified several external pressures shaping oncology VBP: regulatory and policy changes, payer utilization management, consolidation of health systems, workforce shortages, rising drug and treatment costs (including CAR-T and other personalized therapies), and socioeconomic factors that affect adherence and access. These forces amplify implementation challenges, particularly for small and rural practices that often lack infrastructure, data-sharing capacity, and sufficient patient volume to meet performance benchmarks.
Top barriers to effective VBP implementation were administrative complexity, financial risk and unpredictability, and misaligned stakeholder incentives. Panelists argued that current risk-adjustment methods insufficiently account for patient acuity, disease heterogeneity, and SDOH, creating unfair comparisons and financial exposure for providers treating high-need patients. Frequent policy changes and short-term payer incentives further complicate stable model adoption.
Recommendations from the panel include simplifying reporting and reconciliation processes, increasing and expanding enhanced monthly payments to better cover care coordination, incorporating advanced clinical and social risk adjustment, pairing cost metrics with clinical outcomes, and adopting gold-carding mechanisms to reduce administrative burden for high-performing providers. To build trust and enable iterative improvement, panelists proposed pilot models focused on a single cancer subtype in research-oriented payer-provider collaborations, with initial upside-only or hold-harmless periods and transparent data-sharing to develop clinically meaningful benchmarks.
The panel noted limitations of the study: a small expert sample, an imbalance between provider and payer representation, and the absence of patient voices. Despite these limits, participants achieved full engagement across both survey rounds and discussion and highlighted consistent concerns about impacts on smaller practices.
The authors conclude that future oncology VBP models must align incentives across stakeholders, accommodate clinical complexity, and evolve iteratively to support innovation, equity, and financial sustainability. Strengthened risk adjustment, oncology-specific outcome measures, and reduced administrative burden are crucial to making value-based oncology care practical and equitable.
This supplement was sponsored by Johnson & Johnson. Panelists disclosed employment and consulting relationships with various industry and healthcare organizations; some participants were compensated for roundtable attendance but did not receive honoraria for manuscript preparation. Correspondence: Lalan Wilfong, [email protected].
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