Community Oncologists Face Turning Practices 'Upside Down'

Robin T. Zon, MD; James N. Frame, MD; Ray D. Page, DO, PhD


June 08, 2015

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Robin T. Zon, MD: Hello. I am Robin Zon, vice president and senior partner at Michiana Hematology-Oncology in South Bend, Indiana, and clinical practice committee chair of the American Society of Clinical Oncology (ASCO). Welcome to this edition of Medscape Oncology Insights, coming to you from the ASCO 2015 Annual Meeting.

Community oncologists are facing increasing challenges in their practice. Today we will provide an overview of several of the most pressing issues, including payment reform, alternative payment models, and pathways. Joining me for this discussion is Dr Ray Page, president and director of research at the Center for Cancer and Blood Disorders in Fort Worth, Texas. Welcome, Ray. And Dr James Frame, clinical professor of medicine at the Robert C. Byrd Health Sciences Center of the West Virginia University School of Medicine, and medical director of the Charleston Area Medical Center Cancer Center in Charleston, West Virginia. Welcome, Jim.

James N. Frame, MD: Thank you, Robin.

Good Riddance to SGR. Now What?

Dr Zon: In the recent State of Cancer Care in America report[1] released by ASCO this spring, there was a survey of community practices asking what the top pressures are that affect their ability to deliver care to patients. The top two that were cited in community practices, whether they were independent practices or practices affiliated with hospitals, were payer and cost pressures. Dr Page, what do you think about that in terms of how we and society are responding to those pressures from a political standpoint?

Ray D. Page, DO, PhD: In regard to the payer and cost pressures, I think the medical community is extremely excited about the recent repeal of the Medicare Sustainable Growth Rate (SGR). The SGR formula, which was in effect for more than a decade, has been a flawed formula that puts at risk and threatens Medicare payments for practices all across the United States. With that ongoing threat, we have worked for more than a decade to try to resolve that problem, and the medical community has been very excited this year with the bicameral, bipartisan support to repeal that SGR.

The important thing about the SGR repeal is that we now have a more predictable payment year-over-year for Medicare. In addition to that, the government has created incentives to help practices explore alternative payment models.

We're still trying to determine what that alternative payment model should be.

Dr Zon: You're exactly right. One of the highlights of the SGR repeal is the fact that we'll have to comply with alternative payment models. As I recall, by 2016, 30% of Medicare payments have to be tied to alternate payment models, and by 2018, 50% of Medicare payments. Now, I can speak from my experience within our group. We're still trying to determine what that alternative payment model should be. So, Jim, tell me what your practice is doing to address that upcoming regulation.

Dr Frame: I think that the SGR has opened the way for dialogue. At my center, it has allowed me to engage with our administrative leadership and those who look at healthcare delivery about how to see this in the context of oncology. Previously, with the pre-SGR debate, it was kind of hard to see where things were going, although I think professional societies were developing alternative payment models. In this post-SGR window of preparation, we are coming together at an opportune time to address these issues.

I've been discussing matters with our own healthcare system, and the ASCO payment model is one that has been of interest and is actually being reviewed right now with its recent release.[2]

Dr Zon: Jim, that surprises me a little bit. The reason I say that is because my understanding was that you're hospital-affiliated, correct? I was considering that hospitals would be looking at the accountable care organization (ACO) type of alternative payment model, but it sounds like you're doing something a little different.

Dr Frame: We're looking at the ASCO model and our financial folks are breaking things down step by step. What the model allows—for our financial personnel and physicians alike—are categories of payment, categories where we define the care that we provide to patients, many of which are not really articulated in other types of payment delivery plans. The general components of the model allow our financial department to have discussions with our team, looking at our patient volumes and categories of patients to see where we would fit in in comparison to how we are currently providing care at our site.

Oncology Medical Home, Sweet Home?

Dr Zon: That makes perfect sense. In our own practice, what we are looking at is perhaps an oncology medical home–type model.

Ray, you were involved in a very interesting oncology medical home project. Could you tell us a little bit about that and what your thought is about that particular option as an alternate payment model?

Dr Page: Yes. In general, there is a desire to make a move toward fee-for-service, which we've all lived under, where we get paid for the doctor-patient interaction and nothing beyond that. As we look for ways to improve the quality of healthcare that are also associated with cost savings, one of the ways that we can best manage that beyond the doctor-patient relationship is through an oncology medical home. Barbara McAneny from the New Mexico Cancer Center got a Centers for Medicare & Medicaid Services (CMS) Innovation Grant that was $19.8 million for the COME HOME Community Oncology Medical Home Project.[3] Seven practices across the United States have participated in that, and my practice is one of them.

This was a basic medical home structure for which we basically turned our practice upside down in order to more comprehensively manage our cancer patients well beyond just administering chemotherapy. It involves 24/7 access to care and physicians. It required us to centralize our phone calling, have triage nurses and navigators, and enhance patient education. Many of these elements were to help keep people out of the emergency room and hospitals, and to proactively manage those patients by trying to anticipate problems. Some of the oncology medical home structure was designed under pathways—treatment pathways to better manage our chemotherapy, and pathways that were guided toward the prudent use of laboratory and molecular diagnostic tests.

We've been under that program for the past 3 years, and we believe that this infrastructure of patient care can actually improve the value of cancer care by enhancing quality and reducing cost.

Should Treatment Pathways Be More Comprehensive?

Dr Zon: Excellent. You brought up the issue of pathways. Thank you for that. One of the concerns among our payers is that there are unnecessary costs that are driving the healthcare dollar up in terms of expenditures. That includes the acute care setting when you look at emergency room visits and hospitalizations. As you mentioned, Ray, we also have 24/7 triage available to help mitigate some of those issues. Then, of course, there are issues with drugs and variation of usage.

One of the intents of the pathways is to try to reduce variation among many aspects of care. You mentioned that you have a pathway that is helping you make choices in regard to drug utilization. I would suggest—and you may agree or disagree with me—that pathways really should be much more comprehensive. You alluded to that, Ray, when you were saying that there is a continuum of care in which we can have great impact in terms of delivering high-quality, high-value care, which includes avoiding unnecessary testing. Perhaps the continuum should include diagnostics, imaging, surveillance, palliative care, and especially end-of-life care. I have heard personally from some pathway vendors that the end-of-life cost is quite exorbitant and that we might be able to better control some of those costs. Jim, what are your comments and thoughts about that?

Dr Frame: In our particular healthcare region, pathways have come up when discussing the payment reform models, and being hospital-affiliated, it creates a unique discussion. Oncologists are part of the healthcare system and want to avoid unnecessary trips to the emergency room or hospitalizations, yet the hospital system has revenue generation from caring for patients who go to the emergency room. That's a unique situation to consider. In discussing this matter with our own leaders, I think folks had taken the gloves off and were able to talk openly, to consider what's right for our patients and to try to limit those who have to go to the emergency room or hospital so that we can avoid those types of costs. I think it has been an open and healthy discussion so far.

Big-Ticket Item: Not Drugs, but the Acute Care Setting

Dr Zon: I like the point you brought up in regard to cost. I think there's a myth out there that most of the driving force of cost is drugs, when in fact that isn't the case. I understand that an article published in Health Affairs in 2014 reported the main driver of the cost of healthcare [for patients with advanced cancer] was the acute care setting.[4] It was 48% of total costs with a variance across the country of 60%+. But drug costs in regard to chemotherapy were only 16% of total costs, with a variance of 10%. So some may argue that we are already doing a good job in controlling drug costs, but perhaps where we could really contribute is with the acute care setting, as you just described.

Dr Frame: Just prior to coming here, I had an opportunity to see a patient who had completed whole brain radiation therapy. He had run out of his antiemetics and his dexamethasone (Decadron®) was being tapered down. He was in my office with his head in his hands, sick and nauseated. The question is, how do you help that person? You could go ahead and call 911, have the emergency room take care of the patient. But we utilized our chemotherapy suite to give some IV hydration and IV antiemetics, and we were able to avoid the hospitalization. We needed about 3-4 hours with that patient in our office, and we had to give precertification rapidly for that. But that was one way that we were able to help. These issues sort of fold into your day-to-day routine, and you can't always predict when they will occur. I think this is one of the ways to help our folks and save on cost.

Payment Reform and Concern About Penalties

Dr Zon: To your point, Ray, in regard to payment reform, we are pushing for reform that gets somewhat away from a fee-for-services model, as you had pointed out. The way that we're paid currently is based on how much face-to-face time we spend with our patients. But as you know, we provide a vast array of services including, just as you indicated, being able to take care of that patient at a second's notice, but also through patient education, navigation, nutrition counseling, and genetic counseling in some settings. Yet, we don't get paid for that. Payment reform going forward—through an oncology medical home, for example—needs to allow us to be flexible in the services we can provide and be able to be comprehensive in what we're providing our patients.

Within the payment reform models—Ray, I want to get your opinion about this—there is a tie to quality and value and a reward system, but there is also a penalty system that is somewhat concerning to me. As we go into this new world of healthcare system reform, I'm a little worried about the penalty system being implemented sooner rather than later. What are your thoughts about that? How much time should we be giving clinicians? How much guidance should we be giving practices so that they're ready for that next phase?

Dr Page: Penalties always worry me because they can obviously affect your budget and your strategic planning, but there has to be a level of accountability with physicians and their practices. Without a doubt, the best management of a cancer patient goes well beyond that doctor-patient interaction. It indeed takes a village to get patients through their journey with cancer. But many of those elements are not appropriately paid for. I think what we're excited about is the ability to create an alternative payment model where you can have such things as bundled payments, episodes of care, or gain shares to allow the physician's practice to have more flexibility in how they're going to be paid to sustain the practice. But there also have to be elements of accountability with that.

Accountability...should be spread across the entire village of stakeholders, which includes payers.

I think that as we develop these things—maybe we consider simple approaches such as the Choosing Wisely® program or ASCO's Quality Oncology Practice Initiative (QOPI®) measures to show our level of accountability—we can create quality benchmarks that are meaningful, succinct, and make sense for oncology. And not that they're the crazy things that we see sometimes; they just need to be meaningful measures that provide a high level of care that would give the incentive to practices to get those potential financial rewards from those alternative payment models and minimize the risk of having penalties.

Time to Share Accountability and Costs

Dr Zon: I agree with that comment. And you mentioned the word "accountability." I want to talk about that just a little bit. Certainly, I would promote that, as physicians, we are the drivers in many of these reforms, but we shouldn't do it in a silo. The accountability, in my opinion, should be spread across the entire village of stakeholders, which includes payers.

We had a discussion recently about the challenges that we're having in terms of prior authorizations, for example. We should absolutely be accountable, but don't you think, Jim, that other folks should be accountable for their stake in the ground? Whether it's the payer, whether it's the purchaser and the employer, or whether it's the patient who sometimes asks for things that may not be reasonable. What are your thoughts about that?

Dr Frame: I have some deep-seated feelings about this. My nurse is an oncology certified nurse, and it turns out that she's also a minister. Recently I had the chance to speak with her as we were in between patients, and I noticed that she wasn't feeling so happy. She normally has a lot of energy, zest, and zeal and is really out there helping patients dynamically. But what was distressing her was that she was trying to fill out paperwork to have prior authorization for promethazine (Phenergan®) by Medicare. In fact, it was not just one but two episodes of that. Sometimes it works a little better for some patients than others.

When dealing with dose adjustments such as in a colorectal regimen, typically we'll maybe have a dose level -1 or a dose level -2 reduction, but we were having pushback from the payer about authorizing those particular numbers because they weren't the exact doses that you would have with the standard regimen. However, we as oncologists know that we need to adjust and adapt these regimens so that they're safely administered to our patients.

The frustrating part is that as we try to do things that are safe, there are barriers, and these barriers can be overwhelming. There were barriers for the patient who needed to get the promethazine before my nurse had the frustration of dealing with it. First, my patient went to have the prescription filled and could not have it filled, which generated a call to the office, which then generated additional work. There is a lot of this that impacts practices, academic centers, and wherever this sort of care has to be delivered. And that time spent and the commitment and reinforcement for all of this is borne by the practice, not by the payers or the insurers. We need more of a dialogue as we talk about quality, value, and caring for our patients so that the village, as Ray mentioned, can come together and start to really evaluate this and align with true north for our patients, and not the distractions—the magnetic north—that seem to take us off track and frustrate us so.

Dr Zon: Thank you for that example. We're nearing the end of our show. Thank you very much for your opinions. I think, looking to the future, that there is going to be a lot of change. There is uncertainty and it may be confusing for some practices. Which alternative payment model should I be involved with? Which payment reform model should I be considering? Ray and Jim, thank you for your thoughts on these issues.

Thank you for joining us for this edition of Medscape Oncology Insights. This is Robin Zon, reporting from ASCO 2015.


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