Tag: a-conversation-with-leslie-t-busby-m-d-perspectives-on-oncology-practice-value-based-care-and-policy-challenges

Leslie Busby, M.D., senior vice president and chief medical officer of The US Oncology Network, discussed the changing oncology landscape with Managed Healthcare Executive, addressing independent practice models, consolidation pressures, value-based care, and recent policy and pricing shifts. The US Oncology Network, a McKesson subsidiary, comprises about 2,700 providers in 31 states.

Busby began practicing at Rocky Mountain Cancer Centers in Boulder, Colorado, in 2002. She joined The US Oncology Network Pharmacy & Therapeutics Committee around 2005, focusing on drug safety, electronic health record regimen development and pharmacy operations. She later chaired the committee for six years and became chief medical officer in July 2025. Despite expanded administrative duties, she continues to see patients one day a week.

Independent oncology practices face mounting financial and operational pressures from rising costs, constrained capital and payment disruptions, including those caused by cyberattacks. Private equity and hospital system affiliations offer capital and scale but can require loss of autonomy. The US Oncology Network uses a hybrid model that provides financial risk-sharing and management support to help physician practices remain independent while retaining control.

Policy incentives and payment differentials favor hospital-based care in many cases, allowing hospitals to charge more for outpatient services and accelerating consolidation. Busby warned that such trends disadvantage independent practices and heighten sustainability concerns.

Value-based care in the Network is driven by a pathways program now called Value Pathways, developed in partnership with NCCN. The program, originating from clinical work on lung cancer, emphasizes prioritizing scientific evidence, minimizing toxicity and considering cost. Pathways aim to streamline care, reduce denials and improve consistency. While targeted therapies have produced dramatic results in some cancers, accelerated approvals with limited data pose adoption challenges; the Network applies a conservative review before incorporating new agents into pathways.

Pathways closely align with NCCN guidelines, and most Network physicians exceed 75 percent adherence to internal pathways and often surpass 90 percent adherence to NCCN. Despite this alignment, prior authorization remains a time-consuming manual process. Busby advocates for interoperable systems that would allow payers to automatically approve guideline-consistent regimens.

Emerging therapies present both promise and complexity. CAR-T cell therapies offer curative potential for some patients but require significant infrastructure and carry high costs. Gene therapies for conditions such as sickle cell disease are similarly transformative but come with multimillion-dollar price tags. Bispecific antibodies may offer a more manageable cost and toxicity profile by spreading expenditures over time as clinical experience grows.

Precision medicine and next-generation sequencing have become standard in lung cancer, with uptake exceeding 90 percent, and are expanding into other tumor types. Challenges include keeping clinicians up to date and obtaining timely results. Advances in artificial intelligence and genomic testing may soon enhance mutation prediction and treatment selection, potentially reshaping how patients are matched to therapies.

Recent changes in drug pricing policy present concerns for community oncology. While capping patient out-of-pocket costs is beneficial, new pricing and reimbursement rules can undermine the financial viability of independent providers if payments do not reflect true costs. Busby noted shifts by manufacturers toward biologics and antibody-drug conjugates following provisions in the Inflation Reduction Act that limit exclusivity for oral drugs. Uncertainty around average sales price–based reimbursement and the resulting cash flow risks for practices raise worries about unintended consequences for innovation and patient choice.

Looking ahead, Busby identified balancing innovation with affordability as the central challenge. She emphasized the need for robust data to justify new therapies, streamlined payer processes to reduce administrative burdens, and policy reforms that protect independent practices. With aligned incentives and improved infrastructure, she said, precision medicine and AI could make oncology care more personalized, efficient and effective.

Leslie Busby, M.D., senior vice president and chief medical officer of The US Oncology Network, discussed the changing oncology landscape, including practice consolidation, value-based care, precision medicine and policy pressures, in a conversation with Managed Healthcare Executive. The US Oncology Network, a subsidiary of McKesson Corporation, comprises about 2,700 providers in 31 states.

Dr. Busby began practicing at Rocky Mountain Cancer Centers in Boulder, Colorado, in 2002. She joined The US Oncology Network Pharmacy & Therapeutics Committee around 2005, later chaired the committee for six years and assumed the chief medical officer role in July 2025. Despite expanded administrative duties, she continues to see patients one day a week.

She describes consolidation as a response to limited capital and rising costs that leave many independent practices vulnerable. Private equity and hospital systems offer capital and scale but often require practices to cede autonomy. The US Oncology Network follows a hybrid model that aims to help practices remain independent while sharing financial risk and providing management support.

Policy and payment shifts concern Dr. Busby, particularly incentives that favor hospital settings, where outpatient services can command higher prices. Consolidation, she says, has accelerated and placed independent practices at a competitive disadvantage.

On value-based care, The US Oncology Network has run a pathways program for more than 15 years, now called Value Pathways and powered by the National Comprehensive Cancer Network (NCCN). Originating from work by former network CMO Marcus Neubauer, the program emphasizes “science first, toxicity second and cost third.” According to Dr. Busby, the approach streamlines care, reduces denials and improves consistency. She cautions that accelerated regulatory approvals can introduce drugs with limited evidence, so the network takes a conservative approach before adding such agents to pathways.

Pathway adherence aligns closely with NCCN guidelines, with most physicians reaching more than 75% adherence to the network’s pathways and often more than 90% adherence to NCCN. Dr. Busby says that alignment should ease payer interactions, but prior authorization processes remain inefficient. She advocates for interoperable systems that would allow payers to automatically approve guideline-concordant regimens.

Dr. Busby highlighted innovations such as CAR-T cell therapy and gene therapies as transformative but resource-intensive. CAR-T can be curative for some patients but requires substantial infrastructure and comes with high costs. Gene therapies for conditions like sickle cell disease present similar challenges. Bispecific antibodies may offer a more manageable, phased-cost alternative while clinical experience grows.

Next-generation sequencing (NGS) and precision medicine are expanding, she noted, with NGS standard in lung cancer and increasing use in breast, colon and other cancers. The main challenges are keeping clinicians up to date and ensuring timely results. Emerging AI applications could accelerate mutation detection and improve treatment matching, potentially transforming how therapies are selected.

Dr. Busby expressed concern about recent drug pricing policies. While capping patient out-of-pocket costs has value, new laws and regulations can strain the financial stability of independent providers when reimbursement does not reflect care costs. She said manufacturers are shifting toward biologics and antibody-drug conjugates after the Inflation Reduction Act limited exclusivity for oral small-molecule drugs and allowed price negotiations beginning seven years postapproval. Practices can face cash-flow risk when placed between reimbursement streams, and uncertainty around average sales price–based payments remains unresolved.

Looking ahead, Dr. Busby identified balancing innovation with affordability as the central challenge in oncology. She called for robust data to justify new therapies, streamlined payer processes to reduce administrative burden, and policy reforms that preserve the viability of independent practices. If incentives and infrastructure can be better aligned, she said, precision medicine and AI could make oncology care more personalized, efficient and effective.

Leslie Busby, M.D., senior vice president and chief medical officer of The US Oncology Network, outlined the pressures facing community oncology and the network’s strategy to help independent practices survive and compete.

A longtime leader within The US Oncology Network Pharmacy & Therapeutics Committee, Busby joined Rocky Mountain Cancer Centers in Boulder, Colorado, in 2002 and became involved with the network’s P&T Committee around 2005. She chaired the committee for six years and assumed the chief medical officer role in July 2025. Despite expanded administrative duties, she continues to see patients one day a week. The US Oncology Network, a subsidiary of McKesson Corporation, encompasses about 2,700 providers across 31 states.

Busby described consolidation and capital constraints as key forces reshaping oncology. Small independent practices face rising costs and payment disruptions that strain cash flow. Private equity and hospital systems offer capital and scale but often require practices to cede control. The US Oncology Network’s hybrid model seeks to preserve physician independence while sharing financial risk and providing management support.

Value-based care in the network centers on a long-running pathways program, now called Value Pathways and powered by the National Comprehensive Cancer Network (NCCN). Developed more than 15 years ago, the program emphasizes “science first, toxicity second, cost third,” Busby said. The approach aims to standardize care, reduce denials and improve consistency. Most network physicians exceed 75 percent adherence to internal pathways and often surpass 90 percent adherence to NCCN guidelines, she noted.

Despite alignment with guidelines, prior authorization remains a persistent administrative burden. Busby said the bulk of requested therapies are ultimately approved, yet manual authorization processes waste clinician time and slow care. She advocates for better system interoperability so payers can automatically recognize guideline-consistent regimens.

On innovations, Busby called CAR-T “remarkable” for its curative potential in some patients but warned it requires extensive infrastructure and carries extremely high costs. Gene therapies for conditions such as sickle cell disease show promise but come with multimillion-dollar price tags. Bispecific antibodies may offer a more manageable cost and toxicity profile, with spending spread over time as clinical experience grows.

Precision medicine and next-generation sequencing (NGS) are expanding rapidly. NGS is now standard in lung cancer, with uptake exceeding 90 percent, and is increasingly used in breast, colon and other cancers. Busby highlighted challenges in keeping clinicians up to date and obtaining timely results. She pointed to emerging applications of artificial intelligence that may predict mutations from pathology slides and the growing ability of genomic and gene-expression data to forecast treatment response.

Busby expressed concern about recent drug-pricing changes and their unintended effects on independent providers. While capping patient out-of-pocket costs is a positive goal, new laws and regulations, including features of the Inflation Reduction Act, have shifted market incentives. She said some manufacturers are moving toward biologics and antibody-drug conjugates after IRA provisions limited exclusivity for oral small-molecule drugs. Practices positioned in the middle of reimbursement flows face cash-flow risks, and uncertainty around average sales price–based reimbursement remains unresolved. These dynamics, she warned, could reduce innovation and constrain patient choice.

Looking ahead, Busby identified the core challenge as balancing innovation with affordability. She called for robust clinical data to justify new therapies, streamlined payer processes to cut administrative burden, and policy reforms that do not disadvantage independent practices. If incentives and infrastructure can be better aligned, she said, precision medicine and AI could make oncology care more personalized, efficient and effective.