Evolent Health, Inc. (EVH) Earnings Call Transcript & Summary

Good afternoon, and good morning, all. Thank you so much for joining us today. I'm John Johnson, the Chief Financial Officer of Evolent Health. And I'm very happy to have with me members of our New Century team as well as physicians from 2 of our customers to present a panel on oncology care reimagined. If you flip to the next slide here, we have posted the presentation that we'll be using today on the IR section of our website. And if -- we may make certain statements during today that are covered by the safe harbor statements on Page 17 of that document. As we think about how we'll spend the next hour, what we really wanted to do today was highlight the work that we're doing with the New Century team. So you're not going to hear a lot from me. I'll spend about 5 minutes going through an Evolent quick overview. And I'll turn it over to Dan McCarthy, the CEO of our New Century Health subsidiary, to do a slightly longer overview of New Century. At which point, he will turn it over to Dr. Monica Soni, who will introduce our panel and lead us through a Q&A session there. At the end, we'll have plenty of time for questions. So please feel free as we're going through a lot of questions in. We will do the Q&A session at the end. I want to have -- make sure we have plenty of time for that. So without further ado, if we can flip into the next page, Evolent has been a leader in value-based care since our inception 10 years ago. We originally formed in August of 2011, went public in 2015, approaching $900 million of revenue for fiscal 2021 and showing the EBITDA margin that you see on the page. We have 1 mission and have had the same mission since our founding, which is the change the health of the nation by changing the way that health care is delivered. And we focus on delivering on that mission through 2 core segments: A set of clinical solutions in our Clinical Solutions segment accounting for about 65% of our year-to-date revenue and a set of administrative solutions in our Evolent Health Services segment that account for about 35% of our year-to-date revenue. If you flip into the next page, let's dig deeper into our Clinical Solutions set for today, specifically into New Century Health, where we focus on specialty care management for oncology and cardiology and really driving clinical value in a way that is deeply aligned with community physicians to ensure the best outcome of quality for patients and save money for our customers who typically are our health plans or risk-bearing providers. If you flip to the last page, and I will then hand it over to Dan McCarthy. The place that Evolent sits in the new health care ecosystem is as the bridge between the payer community and the provider community. And one of the things that we like most about this positioning is our ability to work with entities really across the spectrum, whether it is a large health plan like Humana or Florida Blue, we're going to hear today, or a new start-up risk-bearing provider like an Oak Street and an opportunity to drive clinical value and partnering with those organizations to ultimately drive the best outcome for patients. And so with that, I will turn mic over to Dan McCarthy.

Thank you, John. Before we get into our panel discussion, let me share a bit more about New Century Health. And you can flip over to the next slide here, please. Our mission is to optimize care journeys for patients with cancer and heart disease by ensuring they align with scientific evidence and patient goals of care. By doing this, we lead to higher-quality lower cost and improve patient and provider experience. We are laser focused on oncology and cardiology given that they are the top 2 leading causes of death in this country and specialties with tremendous clinical complexity and wide variation on cost and quality. We work on a national basis on behalf of payers and risk-bearing providers, as you can see some of our recent wins in the bottom right of this slide. Next slide, please. Before we talk about what we do and how we do it, let's spend a few moments on why oncology is such a challenging specialty to manage. Any discussion about the spiraling cost of cancer care starts and ends with specialty drugs, which, at this point in time, comprise 50% of total cost in cancer and will grow to 80% by 2030. While everyone knows about the 6-figure price tags per cycle, what's less well known is that many of these new drugs lack clear patient benefit. We believe that the goals of cancer care are to help patients live longer or help patients live better. And while there are certainly some game-changing therapies on the market, data shows that, unfortunately, they are more often the exception rather than the rule. You can see here 1 study that shows that only 25% of new oral cancer drugs in a 7-year period had any survival benefit whatsoever in a real-world cancer practice. Another study shows that only 6% of drugs approved in an 11-year period had a meaningful and measurable quality of life improvement. So many drugs hitting the market costing substantial amounts of money, but not necessarily helping patients live longer or live better. Meanwhile, perverse incentives exist left and right in oncology, given that 30% of the economics of the practice are tied directly to drug margin either through rebates or buy and bill. In pharma aggressively markets to physicians who with the stroke of their pen or keyboard control the decision of drug X versus drug Y. Next slide, please. And making that decision of Drug X versus drug Y is an increasingly tall order for oncologists given the tsunami of new drugs and indications hitting the market. An oncologist would need to spend 40 hours a week of time they don't have to do the homework to keep up. And keep in mind, on average, there are typically 7 to 10 regimens from which to choose often approved based on clinical trials that make apples-to-apples comparisons impossible. On the patient side, 42% are medically bankrupt within 2 years of diagnosis, sometimes for drugs that are not helping them live longer or live better. And more than 70% of spend in cancer is within the last 12 months of life, yet data shows that patients are not having the conversations they want to have with physicians around palliative care and end-of-life issues. Next slide, please. Now let's talk about what New Century Health does to address this challenging situation. At the simplest level, we do 2 things: we create value-based treatment pathways that separate the optimal from the available and then we work really hard to make sure they're actually followed. Given all of the issues we just talked about with specialty drugs, we do the hard work of comparing all the available regimens. This is where our clinical team of physicians, pharmacists, data scientists and nurses spends a bulk of their time. They start with the national compendia and then drill down into every and any piece of data that exists to compare the available regimens first on effectiveness, second on side effects and third on costs. We then engage our independent scientific advisory board of leading oncologists across the country to get their feedback before finalizing what we call our Level 1 precision pathways. So in this middle example, we will deem B and E superior options to the others based on the criteria we just discussed. Ultimately, we will still approve any of the other regimens since they're on compendia, but we will try to influence the physician to choose B or E, since we think they are the high-value options. And you can see on the right, the cost difference for 3 solid tumor examples between a Level 1 regimen and a Level 2 regimen. Next slide. You can have the absolute best pathways in the world, but if you can't convince physicians to use them, then ultimately, they are meaningless. So we focus an extraordinary amount of New Century Health on behavior change. Starting on the top left and going clockwise, through CarePro, we put a lot of focus into thinking about how to nudge and encourage high-value choices through our technology. The dose rounding module discussed in our recent call is a good example of this. We also have a significant amount of data that allows us to benchmark and compare physicians on quality indicators, which is a very powerful tool. We can facilitate expert to expert clinical consults which allows us to engage with local practices as peers on scientific evidence. And finally, given the perverse financial incentives we discussed in oncology, we can deploy our portfolio of alternative payment models to align with physicians based on the quality and cost metrics that matter. Next slide. What we do works? You can see here the before and after in terms of the improvement in pathway adherence on the left side from a Medicare Advantage plan. You can also see on the right side, a similar view for cardiology, where appropriate use criteria is a quality measure analogous to Level 1 adherence. We are extremely proud of these results, and we believe behavior change from physicians is the only sustainable way to drive value in specialty care. Next slide. In terms of where we're going strategically in oncology, we see a future where we will continue to partner in even deeper ways with practices clinically, operationally and financially. We then will make a big push into patient-facing capabilities, starting first and foremost with advanced care planning services for vital decisions, but potentially in the future, thinking about things like second opinion or navigation. And we believe by going deeper on the physician piece and going deeper on the patient piece in bringing those 2 things together, that will allow us a unique opportunity to go to a payer and unlock substantial value across the end-to-end continuum of care. ultimately in service of the quadruple and you see at the bottom, which is higher quality, lower cost and better experience for patients, caregivers and providers. Next slide. Given that Vital Decisions is a foundational piece of our patient-facing strategy, I'd like to provide a quick status update. At this point, we are 45 days since closing the transaction. I continue to be extremely impressed with the team at Vital Decisions, which is now fully integrated into New Century Health. While it's still early, we've had strong momentum on cross-sell opportunities, which is a validation of the deal thesis on the combined value prop of the organizations and most importantly, Phase 1 of the product integration work is underway to bring this vision to reality. Next slide. Let me end with an illustrative case study that gives a glimpse into this exciting product vision I just referenced. You can see here, John, who's an 81-year-old man diagnosed with curative lung cancer, whose oncologist has requested to treat with radiation therapy. When New Century Health gets involved rather than immediately approved, we review the PET scan, notice an anomaly and suggest a biopsy. That biopsy ultimately confirmed that it's metastatic disease, sadly no longer is this a curative case and radiation therapy will not benefit John. On behalf of his oncologist, a specialist from Vital Decisions reaches out to John to engage him early on around his preferences and goals of care. Through the series of discussions with the Vital specialist, John determines that should his cancer prove eventually unresponsive to treatment, he would prefer comfort care. The specialist works with John to document this into a clinically relevant advanced directive and with his permission shares that with his oncologist and connects him into palliative care services. Meanwhile, now that radiation is no longer relevant, the oncologist request to treat John with a checkpoint inhibitor, but New Century Health first request the genomic test to make sure that John is a good candidate to benefit from the treatment. That test unfortunately shows that John has a genetic mutation such that he will not benefit from the checkpoint inhibitor and the oncologist switches therefore to a single agent therapy with a lower toxicity profile. John continues on that regimen for 14 months before his tumor eventually is unresponsive to treatment. At that point, the oncologist reconfirms with John that his preferences and goals are to move to comfort care. John spends the last months of his life at home, surrounded by loved ones and friends, consistent with his goals of care. If not for this integrated approach across New Century and Vital Decisions, John would have failed extremely poorly. You can see here at the bottom, several stats on cost savings and survival benefit and quality of life improvement, but most importantly, there's goal concordance with how John wanted to live his life. And with that, I will end and pass to Dr. Monica Soni, our Senior Medical Director, who will facilitate the panel discussion.

Thank you so much, Dan. It's always helpful to re-center around the patient, which is really why we're all here. So I appreciate that segue. I'm really happy to be joined by my illustrious panel, I have Dr. Andrew Hertler, who is our Chief Medical Officer at New Century Health, an important certified medical oncologist with over 30 years of experience, both treating patients and running practices in academic and community scenarios. Dr. Bryan Loy is a Corporate Medical Director at Humana, who provides clinical leadership over all cancer initiatives, is an oncology and laboratory subject matter expert with over 20 years of peer experience and an industry-recognized physician executive who has consistently improved both quality and value. Finally, Dr. Beth Malko is Florida Blue's Vice President and Chief Medical Officer for Medicare Solutions. In this role, she ensures members receive evidence-based medicine and coordinated care. She has over 20 years of experience in managed care and has led large and diverse teams in clinical transformation and innovation. Thank you, guys, for joining me today, and I'm really excited to hear your input both on the oncology landscape and your partnerships with New Century Health. So Dr. Malko, I'm going to start with you. As a CMO of a large peer, can you please share why did you select New Century Health as your partner versus other options? What were some of the differentiators that were key in your decision-making?

These were services that Florida Blue Medicare was already performing. But we didn't have either the oncology expertise or those relationships. I think Dan did a great job describing importance of being able to have those conversations with oncologists, and that oncology conversation is critical. And we didn't have that expertise. Further Florida Blue, both in our Medicare and commercial lens of business, really has very little interest at this point in having vendor relationships, at least on the clinical side. We are really looking for partnered relationships. And New Century really came to the table and was willing to take on a risk-based relationship for oncology care for our population of members. That's a critical relationship for us to have. We want to work together to improve the care of our members and keep cancer care affordable. And so those are really the key elements for us.

Thank you. And I think that's so important. That is how we think of ourselves as really as a partner. Beth and I had a conversation earlier this week where we were just looking at some of the quality metrics for the patients that we share. And again, brainstorming, how do we make sure that low-value care isn't being delivered. So again, it's really like working hand-in-hand until problems solved. The thing that's challenging is we know that physicians who are practicing these enormous administrative burdens and it's challenging. Dr. Hertler, can you share what are you hearing from frontline oncologists? What is it like for them to work with New Century Health? How do you mitigate some of those challenges? You are on mute, Dr. Hertler.

No doubt that prior authorization is a tool that's been used in health care for decades, but with the escalating price of cancer drugs, there's been renewed focus on it by payers as well as policymakers over the last 5 to 10 years. And there's no doubt that the administrative burden is huge. And 1 publication in health affairs primary care practices and their physicians and staff, we're spending 20 hours a week obtaining prior authorization, and I suspect that within oncology practices, this burden is as great or greater given the large number of drugs that are utilized. And what we're hearing from oncologists is, one, the burden that this puts on them in the middle of a busy practice when they want to be focusing on taking care of the patients as well as some disturbing reports of care to patients being delayed while awaiting prior authorization. There is another side to this, however, in that in talking to oncologists, there's a real understanding that when these treatments are costing $20,000 and $30,000 a month that a payer is going to ask for justification and want to know what they are paying for. There's very much an understanding of that. They also realize that oncology is very complex. In any given clinical situation, there are multiple options that can be chosen and the decision-making on each patient can involve individual genetic mutations within their tumor as well as social determinants. Given this level of complexity, hate to say it, but oncologists will occasionally make a mistake. And they actually do not generally object to someone providing some oversight and catching them if they have missed something. I think probably the one other point that I heard from oncologist not infrequently is the desire to have payment for the drugs they are providing assured. They are laying out and having run a practice. All of the bills for these drugs go to accounts receivable. And you want to make sure you're going to get paid that $20,000 or $30,000 a month for each treatment. And for that reason, they do not object the prior authorization. They do object to the process that is now frequently in place. What I hear about New Century Health is they appreciate our decision support that our pathways help guide the proper treatment. They also very much like the fact that they pick one of our pathway regimens. They get an instantaneous automatic approval. There's no delays in therapy. There's no waiting. There's no faxing of documents. And the comment I hear most often is they wished all payers use New Century Health.

Thank you for that. Mr. Loy, it's been a long relationship between Humana and New Century Health. Share with us how do you think about supporting your network of oncologists in delivering that high-value care that we all seek? And why did you seek a partner in this space?

Let me start with your last question first. But you're right, we've been together for over a decade now. And in many ways, it feels like we've grown together in an ever-changing environment. But my senior leadership insisted that we start out at the onset and being clinically credible. We could not afford to make mistakes. We had to put patient interest first and foremost and do everything we can to be administratively easy to do business with. And so not only was it what we were going to do, but it was how we were going to go on about it was very important to my leaders. And in terms of what that looks like, what that journey look like, as Dan described early on, it was put effectiveness first. Toxicity second, if there was a tie and least costly alternative. But over time, what we've seen is a pipeline that is replete with new technologies, and we see that many times what's coming to market is providing either minimal improvement or there is uncertainty about what improvement it might provide at all over existing standard of care. So we needed a partner that could illuminate that through its scientific advisory board processes that could mitigate the conflict of interest that we felt like as sabotaged some of those efforts in the world of key opinion leaders to bring what we believe is the truth about how much improvement is this over the existing standard of care. And then once we could manage to do what's right, then we went about the business of trying to mechanize that and be helpful to the physician. So in our partnership, we looked for ways to get to a better yes, more quickly. You put yourself in a league of its own when you've got a medical oncologist to sport certified who's practiced or is practicing who has some specialty expertise on the phone with someone from the practice who's got a patient in front of them. And that was very important. It remains extremely important to us today. So those are some of the key features that brought us together. And then as I look towards your second part of the question, I'd say what's changed over time has been this, I'll call it, transition away from comparative studies versus the standard of care and comparative studies that really don't answer the question of are we providing clinically significant and meaningful benefit or improvement on the standard of care. And I think Dan said it best when you're saying meaningful to patients. So in the eyes of the patients, whether it's survival or quality of life, those are extremely important features. And I'd say if they were underscored at the beginning, they're double underscored now. So those are important aspects, and we call it North Stars in our relationship.

Thank you for that. That's a great summary. And it's so true, I think a lot of times in the medical field, there's a sense of doing more is better and more in the space of oncology is a really complicated one, right? The drug is high toxicity. They are high cost, it's difficult to tolerate. And it's so important to upfront have those conversations with the patient. But what do they want? Is it actually like this more that we want to keep offering?

And I think one of the things that has become important in our dialogue in these more current times have been just really calling out the uncertainty. So many of the trials of these new-to-market drugs may or may not include some of the populations that we serve is a Medicare Advantage plan, we're extremely interested in what's the impact on a senior population, for example. A population that may have comorbidities, et cetera. And what are the aspects that we need to be paying attention to in terms of patient convenience. We didn't think much about that prior to COVID, and COVID wasn't in our 5-year strategic plan. But we've learned a lot in terms of the flexibility and just the acknowledgment and appreciation that we're going to have to manage some uncertainty, both with what we know and both with how we apply it. So I'll leave it at that.

No, that's incredibly helpful. You called out a point that I think is so important, right, which is clinical trial inclusion criteria is just clinical trial inclusion criteria. It doesn't necessarily apply to the patient in front of you. And I think this has been an area where there's been a lot of focus on equity, right? And I think you define it as a populations that you serve and it's every demographic, right? It's each group, it's race and ethnicity, it's your patient's preferences, it's the financial risk that they're bearing. So all of that has to come into play when you make decisions, really, really helpful call out. Dr. Hertler, I'm going to kind of pick this question to you. Dan mapped out some of those really concerning statistics. And it has highlighted there is this misalignment between what patients want articulate that they wanted to end their life and the care that we continue to give them as health care professionals. Why has the field of oncology specifically been so challenged in ensuring all patients have access to quality advanced care planning and supportive services like palliative care?

It's a really good question, and I think it's one of focus. And first and foremost is the focus of an oncologist, what they spend years training to do and what their focus in their practices is treating patients. They are treaters. I've had them tell me, they believe patients come to them because they want to be treated. And that is their job to tell them what kind of treatment they should get. A second component of this is that conversations with regard to end-of-life palliative care, advanced care planning are not always easy conversations and not all oncologists necessarily have this skill. Add on top of this the fact that they are generally time strapped. They run a busy practice. Typically, you'll get 15, 20 minutes of face-to-face time with each practice. In oncology, generally, every 8 weeks or so, you will be making certain that whatever therapy is being given is working, that's often with a scan, often done on the day of the visits. So patient comes in, they have their scan and low and behold their cancer has gotten worse. Well, you can do 1 of 2 things. You can walk into that patient room and you can have a very difficult and frank discussion with that patient. It will be emotionally charged both for the oncologists as well as the family and the patient, and there may be tears and it will take more than 15 or 20 minutes. I never figured out in 30 years how to have that conversation in 15 minutes, and I'm not sure I ever want to know how to have that conversation in 30 minutes. That's one alternative. The other alternative is to walk in and tell the patient, your scanning is worse, but I have another treatment for you. Everyone's happy. Your visit just became much shorter. And we've designed a system that in terms of the reward it puts in place. I can tell you from having run a practice, Financially, I do far better treating patients than I do in having those very difficult conversations. That being said, many oncologists do have those conversations, but it is not their focus, whereas a palliative care physician or people such as in Vital, that is their focus, having these discussions on patients. This is a team sport, and they all need to work together.

Thank you for those comments. I think it's sometimes difficult for folks outside of the health care field to hear some of what you have articulated, but it's just the truth. Beth, you're a family practice physician, and we've spent some time talking about that you believe and I as a generalist believe some paramount to help folks die with dignity, like that is just as important as offering treatment. So I know that you, within your organization, have actually already had a relationship with Vital Decisions separately from New Century Health. And can you just talk to me a little bit about philosophically why and now that we're one organization, what kind of synergy are you hoping for between the two of us?

Yes. So -- and you're right. As a family physician, I spent lots of time having those very difficult conversations for not just cancer care but for end-stage COPD and end-stage CHF. And it is a different skill set. I think it is -- I think to hurt this point, it's a very well taken because is that really the skill set that I need for my oncologist or is that the skill set I need from the primary care physician, from the palliative care physician, from the hospice physician. So this feels really natural to have these things come together. For our members, and I agree with what Dr. Loy said earlier, for our members, we think it is absolutely critical that our members receive evidence-based care. It's also equally critical to know when to incorporate the palliative care conversation into the member's journey. And when to incorporate a hospice care conversation. And I think it's important to make that distinction. We think of palliative care as care that is supporting the discussions and the pain control. And the thinking about end-of-life care will not necessarily eliminating potential curative therapy, whereas hospice care, we do say that that's not the time for potentially curative therapy. Now it's about quality of life and comfort and family support. So they are important to make that distinction. We had -- as you noted, Dr. Soni, we had a relationship with Vital Decisions and actually had my last job as well and had the relationship with you all. And it just, to me, makes absolute sense that these would be conjoined. It allows that highly care conversation, and Dan gave a great description of how that can occur. It just makes sense that we know when to have that conversation, and we can bring it in orally so that it's not so threatening. As Dr. Hertler said, you have a bad skin and then you come in and have palliative care conversations so much better to have had that palliative care conversation very early when the patient still has more hope and they can make those decisions with less fear and with less emotion. So I think that it's just really, really important to be able to do that. It just reduces that friction in that time. 30% of Medicare spend -- and I'm in the Medicare business -- 30% of Medicare spend occurs in the last 30 days of life. That doesn't make sense, either financially or for the quality of life of the member or for the family. We know that in many cases, palliative care actually lengthens life. There are some good studies that show a 4 months survival versus 2 months survival. And that's not for every cancer or every individual, but it can make a difference. But what we knew definitively is that there is an improvement in quality of life when you no longer taking toxic drugs, and you have the time not to be slipping back and forth between doctors' appointments and hospitals and outpatient clinics, but to be focused on your family and enjoying the remaining life that you have available. And it's so important for family members. And I think that's the beauty of palliative and hospice care as it goes on beyond the death of the patient. And that's just so important for our members. So for me, the combination of the 2 services is almost intuitively obvious, and we're delighted.

Thank you so much for that. Yes, it's -- it always makes me feel bad to be honest, when I realize that we, as physicians, would mostly not take a lot of the therapies that as a collective we offer, right? Like we would really make sure that the kind of death that we want are going to happen. And unfortunately, we're not always enabling that for the patients that we serve. And that's a big gap that really is. It's really unacceptable. So I'm excited about the relationship between Vital Decisions and New Century, too. I really do hope that we're able to achieve what we all want to achieve for the patients that are at the center. Dr. Loy, you talked a little bit about this earlier, and I want to come back to you here. A lot has changed in the 10 years that the relationship has existed between Humana and New Century Health. In the next 2 years, let's shorten the time frame, what would oncology look like? What do you kind of see coming down the pipeline? And what do we do to keep up with this piece of innovation here?

Yes. I'll start with your last point first. And when I think about innovation, I'm thinking we've got to illuminate and contextualize what's coming into the treatment armamentarium. And I think we have to have a clear enough understanding to be able to not only articulate that if we're taking a position with our partners, but also that we have to be able to act on it in some way. So some of that could manifest in terms of being able to have conversations with practices. Practices who are trying to get the most clinical value out of the dollars that are going to be spent and bringing our insights -- collective insights to the practices and maybe new ways besides just a platform. That's not to say that there are not scalable opportunities, but I think there are also practice-specific opportunities as well as, I'll call it, disease-specific opportunities that we'll need to keep an eye on. And if the current trend continues with approvals on soft endpoints and with our control arms, et cetera, I think there will be even a greater emphasis on the need for shared decision making and informed consent aligned with patient values. And by the way, what I just described also fits a bit further upstream under that umbrella of palliative care. So we've got to come up with some mechanisms to get to know our patients better, our providers better and try to create some alignment where we're collaborating in ways to be able to align with patient objectives as best that we could know them. You can't know them, if you don't get -- if you don't ask those types of questions. So I believe that folks like New Century that are in the business of being able to ask those questions on front-end processes are in a much better position to introduce that type of conversation versus a payer who's looking backwards from claims data, for example. So I think there are new opportunities that are beginning to show themselves. And I believe the planets are starting to align themselves. But it can't be to the exclusion, at least in my opinion, without collaborating with or working through the provider. So there has to be alignment there. We can't fragment the system even worse. But just to recap, I would say we've got to get as good as we can get in establishing processes that not only analyze the, I'll call it, the pipeline offerings, but also getting to know our patients and our providers better.

That's a great point. And let me just ask you to like drill down and Dr. Hertler, you can feel free to jump in a little bit more on this idea that we've alluded to, which is, I called it innovation, but it maybe -- that's maybe a misnomer, right? There's a lot of drugs that are being applied broadly, but maybe not beneficial to patients. And so I don't know Dr. Hertler, if you want to jump in with some of your thoughts about the subgroup analysis, for example, in checkpoint inhibitor is, right? Like are patients actually benefiting from some of these blockbuster drugs as people like to think of them?

No doubt there is some benefit, but it's not what we're seeing in the clinical trials that lead to their marketing. The patients who are treated on the initial trials that lead to approval of drugs are tend to be younger, they tend to be wealthier, they tend to be healthier and have less comorbidities. And whenever you look at how they do, whenever you move it into the real world, I just sort of rule of thumb cut the results in half. A recent very interesting study published in JAMA, the Journal of the American Medical Association looked at Medicare patients treated with the checkpoint inhibitor class of drugs versus those treated with more conventional chemotherapy and looked at their survival. Now I've looked at a lot of survival curves over many, many years as an oncologist. I think I would have to think a long time to find 2 curves that lay on top of each other as much as these do. And there are reasons to think that these drugs might not benefit elderly patients as much as they do younger patients. These drugs harness the immune system. But as we all get older, our immune systems don't work as well. So this is an area where we need to gather more research, look at real-world evidence. But given that these drugs can be powerful drugs, who are they benefiting and how do we identify the subgroups where they benefit, get those drugs those patients. But when patients aren't going to benefit, find another way to treat and manage their illness.

Yes. I love that. It's actually really a more enhanced definition of like precision medicine, right? I think a lot of times, people like to think of it as like you have this mutation, this drug is for you, the end of the conversation. But it's just not the case, right? Like just because those 2 things are true does not mean that you're necessarily going to benefit from it. So I think, again, a lot of nuance in what we're talking about. I think we'll continue to see drugs hit the market over the next couple of years that continue to purport that it's more and more targeted, smaller and smaller mutations that they're focusing on. But are patients going to benefit from in a clinically meaningful way? I think a little bit the jury is really out in that space. Dr. Malko, you share me your thoughts. Over the next couple of years, what do you think is going to happen in the oncology world? And what are some of the ways you're preparing for those changes?

No. When I was a child, and I'm old. When I was a child, a diagnosis of acute lymphoblastic leukemia in a child or Hodgkin's lymphoma in an adult would suggest that means they are 90% curable at this point. I'm not talking remission. I'm talking cure. That's for like wow. And with absolute due respect to all of the concerns we have about the new drugs coming out. There are new drugs that have many tremendous strides. I'm a breast cancer surviver, and I'm very, very grateful that there are drugs out there that can be powerfully helpful for patients, for people. But there's also this opportunity that my predecessors in those conversations have described of drugs that don't be invaluable but at enormous cost and frankly, enormous toxicity to the patient. And so we're very supportive, and we love fact that you'll have really good group of practicing and academic oncologists who are giving you advice and guidance. So we're really looking forward to being able to manage and set expectations with both oncologists and patients about getting evidence-based care that makes a difference for you, the patient in your age range with your specific disease state, with your underlying comorbidities. So I think all of that is going to be incredibly critical. And of course, the fact that Vital Decisions' support continues to be really, really important. But I think the other component for me is looking to NCH to sort of expand what you all are doing. So I think it's critically important that all members get evidence-based care. But being an oncology patient, as you all know, is a very, very scary experience. And incorporating care management and care coordination capabilities, with those conversations and utilization management functions that already exist, I think would be a real value add for NCH, whether it means working with the care management teams in an oncology practice, many of whom have wonderful care management teams working with the health plans care management team. So in addition to working with Vital Decisions, we also have our own supportive care team. We've chosen not to use the palliative care term but the supportive care term, which is actually been really [ not ] accepted or creating member-specific care coordination teams that you all can work with members on as they go through their care journey. So I think at the end of the day that being able to connect getting the right drug to the right patient or the right radiation therapy to the right patient at the right time, but also supporting them through their journey, either working with their provider of their health plan or the member themselves, I think will be a really significant value add and help to reduce some -- both the fear that the member has, but also some of the abrasion. If a provider has already said to a member, well, I'm going to use drug X and then Oh, well, never mind, we're going to use drug Y. That ability to have that care management capability behind that, I think adds enormous value. So I've shared that with NCH, and we're looking forward. I think the last thing I would say is that Dr. Soni mentioned earlier, she and I had a very good conversation about some of the quality data that's being gathered and the ability to look at when and how quality of care is being delivered. And we're very, very excited about that. I think we want our members to go to the providers who're going to deliver them the best care. And to do that, I have to be able to tell them who those providers are or at least give them a range of providers and their performance. So very, very excited about that as well. I see that to a large extent in some of the new frontier out there.

Thank you so much. I think that's just a perfect way to frame it. And it is how we're thinking about it to both you and Dr. Loy really mentioned this, that the provider is a critical part of this, right? And we don't want to be bludgeoning them with paperwork. We want to be in partnership with them. And then the patient, like a member, absolutely, from end to end, we want to be supporting that. So Vital Decisions for us is a step in that direction. We know it's not complete in terms of giving the patient the wraparound services that they need from before diagnosis to your point, all the way to the end. And does the primary care provider know who the high-quality oncologist is? Have we optimized the oncologist? Does the oncologist realize that compared to their peers, they might be doing some medicine that isn't driving value in the ways that the patient the way is thinking about it? So that is absolutely what we are thinking is on the next frontier for us. And we're really excited at New Century Health for this next phase. Any last comments before we start to move into some questions from our audience?

The only thing that I would just add would be that I think when you get into a Medicare population, it will be important for us to also think about how we can take the good information that New Century can bring to us, whether it be a member-specific or practice patterns in general and being able to articulate that to lay audience, not just the patient, but also the caregiving team. They play a very important role when they're available. And when they're not, we've got to find new ways to be able to support that experience because it's a very difficult disease to navigate even under the best of circumstances. And if you're living alone and you have some of the barriers that Dr. Hertler described early on in terms of social determinants of health or just health literacy, those become very important in being able to help people, help patients and their families arrive at good decisions. It's something that's more recently come into the narrative. We've talked about financial toxicity and its impact on survivorship. More recently, we're starting to hear the phrase time toxicity. So if I give someone an extra 2 months because of the benefit that was perceived in a population, which may or may not apply to this particular situation, the patient as well as the caregiving team, they need to understand that, that 2 months might be offset by time getting infusion, time getting their labs, waiting in an infusion center, the risk of being put in the hospital from an adverse effect -- side effect profile. So those are the things that I think, are really going to become important as we begin to try to inform conversations that are helping patients to arrive at their values and share them back with us.

I love that so much. I mean I really think about informed consent as having all of those factors, right? Do you understand what is important to the person? Have you put all of the individualized characteristics at play? And have you, for each of those things, let them know what the rest of the benefit profile might be so, so critical. And maybe I'm just biased, but I sort of feel like Beth and I, as generalists or primary care providers, like that's up the floor of what we thought we should be doing. And I know Dr. Hertler is an old school oncologist. So you said that you always did this when you practice too. But I do think with the time constraints and some of just -- Dan mentioned how many hours per week physicians are spending doing, just trying to get through their day. Some of that gets lost, right? Are you spending the time next to the patient, talking to them about what's important to them, to their caregivers, to their family members, what is their role in the community, what is important to them and then sculpting the next steps based off of that? I mean that really is the art, right, the art that goes alongside everything that we've been talking about from a technical perspective. Dr. Hertler, any last thoughts before we open it up to questions.

I would only say that we've heard a lot about collaboration. And as I look towards the future, we're going to move to an era where there will be a need for that navigation such as Vital Decisions provides. But the ability to connect patients to the services, I always would tell my patients, there's only -- there's no type of cancer that one physician takes care of that -- yes, there's medical oncologists, radiation oncologists, surgeons, but there's the nurses who give the therapy. There are care managers, there are financial counselors, there are dietitians, there's physical therapists, and we need to assemble a personalized team for each and every patient. And that team needs to communicate and collaborate, and they're often at different sites, and there is a real role for us at New Century Health to facilitate getting the services that each patient needs and making sure that all those connections are made.

JJ, what do we have coming in for questions?

Thank you so much for that panel. I'm inspired a little bit just the talk of the quality of care here. A couple of questions came in during the conversation, and I'll just say, please welcome any listener and please drop something in chats. And for some reason, you have a technical problem with the chat, feel free to send me an e-mail [email protected]. We'll try to get your question into the queue as well. This first question, probably is for Dan, in regards to more patient-facing capabilities, is that mostly leveraging Vital Decisions to engage patients in cancer care navigation at end of life? Or is that more broadly across oncology and cardiology?

That's a great question. If you think about our specialties oncology and cardiology, they represent more than 50% of deaths in the United States and even a higher share of end-of-life spend. So initial focus as we think about the Vital Decisions acquisitions is in those 2 specialties. How do we think about fixing the care misalignment problem at the end of life that we spent a lot of time talking about today wherein patients end up having a lot of unwanted or unwarranted care in the last 12 months of life because they're not having conversations about goals and preferences. However, as we think about end of life, I would go to what Dr. Loy said earlier about going upstream or about what Dr. Soni said about the first step as we think about really having the maximum amount of impact we can for patients, you really have to think about the full journey. And there are so many micro decisions that get made throughout a cancer journey, throughout a heart disease journey. And if you think about somebody with cancer or heart disease, that is a complex scary vulnerable time. So again, initial focus around end of life, but eventual vision around how do we go upstream and help patients navigate their journeys in these 2 disease states.

Right. Good. Next question, probably for Dr. Soni to start, maybe. We talked a lot about oncology and misaligned incentives on drugs that can drive savings. Turn to cardiology for a moment, what are the main or equivalent factors of cardiology that would drive most of the savings there?

Yes, that's a great question. There are some parallels between oncology and cardiology, there are obviously some key differences. So I think I sort of tongue in cheek say that cardiologists often like to do the sexy things, right, which is more interventions and procedures, both invasive and noninvasive studies. And really, the truth is what saves lives in the cardiovascular space is not bad, right? It's smoking cessation. It is helping people manage their chronic comorbidities like diabetes and hypertension and hyperlipidemia. It is actually guideline-directed medical therapy, right? So making somebody start actually the 4 medications, which might be difficult to tolerate and checking in with them every couple of weeks and titrating it aggressively to manage their heart failure. So it is -- there are some parallels, right, and making sure that you're not just doing the like new, exciting on the horizon, device or intervention and thinking about what are the foundational pieces kind of very much parallel. And then I think the conversation we've been having about what patients want their value system, absolutely, of course, surprised to cardiovascular disease as well. Somebody has a heart failure diagnosis, especially with reduced ejection fraction, you can prognosticate pretty well like what the next few years are going to look like for them. And so how do you have that conversation with them, right? Before you're starting to do you also had to clearly instruct to them. Have you talked to them about what do they want, how they want to spend that time, what is the caregiver burden so they're not in the revolving door of the hospital? All of that is really important. So some parallels, some differences. It's pending because at the core when you see that actually mortality from cancer has gone down and it has as well for cardiovascular disease. It's mostly from smoking cessation. And right, like that actually has made the biggest difference more than like anything else. And so just making sure we're focusing on the right things and that patients know, right? Like, yes, I can give you this new drug or do this procedure, but actually, maybe we should spend 30 minutes talking about how do you incorporate more exercise into their lives.

It's really helpful. Pause for 30 seconds or so here to see if there are any additional questions from our audience. And then we can look to wrap up, I'll say just preemptively a big thank you to our panel here, both our executives at New Century to Dan, and Dr. Hertler and Dr. Soni and especially to Dr. Malko and Dr. Loy for joining us today. We hope this has been useful. And obviously, happy to follow up any further questions that you have in e-mails, and we hope to see you on the road soon. So with that, I think we will bring it to a close. Thank you all.

Thank you.

Thank you.