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Practice Matters
News about health policy and practice management issues of importance to oncologists
Thursday, March 26, 2015


It’s rare to hear the term “Boehner-Pelosi deal,” but the bipartisan plan to replace the Sustainable Growth Rate formula with a new system for paying physicians shows that House Speaker John Boehner, R-Ohio, and Minority Leader Nancy Pelosi, D-Calif., can agree on a good idea. And the House of Representatives will go along with them.


The Medicare Access and CHIP Reauthorization Act of 2015, approved by the House earlier today, is being hailed by medical societies and anyone else who has been following the SGR mess for years.


Of course, the Senate also has to be approve the bill. If that happens, here are the highlights:

·    Medicare payment rates for physician services will increase by 0.5 percent a year between 2016 and 2019.

·    Starting in 2019, the era of all-physicians-are-paid-the-same will end. Options are available but, in general, physicians will be financially rewarded for providing high-value care and penalized for failing to do so.

·    The Children’s Health Insurance Program will be extended through 2017.


The American Society of Clinical Oncology is totally excited about today’s news: “Cancer incidence among Medicare beneficiaries is expected to increase by 67 percent by 2030, and maintaining a fundamentally flawed payment system could compromise health care access for this growing patient population,” CEO Allen Lichter, MD, said in a news release. “The bill passed today goes a long way to restoring stability in one of cancer care's most vital programs.”


And the American Society of Hematology is glad to see the SGR formula, which has called for reductions in physician pay almost every year since 2002, kicked to the curb:  “While Congress postponed scheduled reductions in the past, this has only provided temporary reprieve, creating an atmosphere of instability that has been highly disruptive to hematology practices,” President David Williams, MD, said in an ASH release.  


Similarly for the American Society for Radiation Oncology (ASTRO): “We are at a turning point for our nation’s health care system. Permanently fixing the SGR with the comprehensive plan outlined in this legislation would be significant,” Board Chair Bruce Haffty, MD, said in a news release. “A stabilized reimbursement plan would strengthen Medicare and allow us to improve quality faster for our patients.”


Meanwhile, the  American Cancer Society Cancer Action Network (ACS CAN) likes the new approach to paying physicians put forth by the House: “The bill would take important steps to reward health care providers for the quality of care they provide rather than the number of tests and procedures they perform, while ensuring the development of sound quality measures,” ACS CAN President Chris Hansen said in a prepared statement.

Saturday, March 14, 2015

I’m on the search for the boldest experiments in paying for cancer care, and the episode-of-care program developed by Regional Cancer Care Associates (RCCA), one of the nation’s largest oncology networks, and Horizon Blue Cross Blue Shield of New Jersey makes the cut.


I heard RCCA President Andrew Pecora, MD, and Glenn Pomerantz, MD, Horizon’s Chief Medical Officer, discuss their plans in this fascinating webinar presented by the National Institute of Health Care Management Foundation a few months ago (click here for this article I wrote earlier this year and scroll to the last section, “Episode-of-Care Payments, New Jersey-style”).


In addition to the payment agreement, Horizon has invested in the cancer outcomes tracking platform being developed by Pecora and other oncologists.

Glenn Pomerantz, MD


I wanted to learn more, so I followed up with Pomerantz. Here’s an edited transcript of our conversation – you can also listen to a podcast of the full conversation in the iPad edition of OT’s April 25th issue.


How did you come to partner with Regional Cancer Care Associates for this initiative?

Glenn Pomerantz, MD:  “They’re a very large group in our state, comprising about 100 oncologists at 24 New Jersey locations. What’s really neat about this whole initiative is that the physicians are the ones who saw the issues facing our patients and said, ‘We’ve got to try and do something to make this right.’


“The oncologists in this group said, ‘First of all, we have to have a data platform. We have to have a clinical way of looking at our patients where data is flowing in real time that properly addresses the molecular phenotype and the staging of our patients.’ Then they said, ‘We need to build bundles of care for each cancer subtype, and then, we will build a technology platform so that we can basically classify and compare and contrast every patient down to the finest level at the most advanced level of the science today.’”



Tell us about that oncology-management data platform. 

“It is a big-data, real-time clinical outcomes tracking platform. First of all, it classifies patients in oncology. I’m a baby boomer, so I liken it to library science and the Dewey Decimal system.


“Today, our language to discuss cancer patients derives from two major systems: One is ICD-9--International Statistical Classification of Diseases and Related Health Problems--and the other is CPT-4--Current Procedure Terminology. Those are the languages of reimbursement and billing and how providers interact with insurance companies and the government. If you look in ICD-9, you will see that breast cancer is just an anatomic classification of the disease that tells you whether the breast cancer is in the upper outer quadrant or in the upper inner quadrant. What it does not tell you is: Are you Stage 1 or Stage 4? Are you progesterone-receptor positive? What is the quality of life? How many lymph nodes were involved if you’re less than Stage 4?


“COTA [Cancer Outcomes Tracking and Analysis, a big data cloud-based program] invented a classification system that basically leap-frogged where we are with our current reimbursement language. Then they said, ‘OK, now we have a new language to communicate and we can properly compare and contrast every cancer patient. We need to be able to deliver that information about how these patients are progressing and their quality of life back to the physicians.’


“In the past, our data systems could capture information about utilization and pharmacy spend they couldn’t capture quality-of-life data. They couldn’t tell us if a patient is back to work and resuming normal activities or if they are disabled 50 percent of the time or if they are having a lot of pain. So COTA built into this classification system the ability to capture functional performance status about quality of life. It can capture the most important things you want to know when you see an oncologist if you have cancer: Overall survival and progression-free survival and dose toxicity, just to name a few parameters.”



How does this episode-of-care program work?

“The physicians in a bundled arrangement with the new oncology data platform will be managing the total cost of care within an agreed-upon price that we negotiated with those oncologists. When you take on the responsibility for that, there’s a learning curve. So for the first two years, we at Horizon don’t want the oncologists to experience any impact to what they would receive normally under a fee-for-service environment. So they are going to get paid the same as if they’re seeing the patients in a fee-for-service environment for the first two years. And we are going to show them every quarter where they are in terms of the cost and the quality of care so that they can learn how to manage all those parameters before they move into a total-cost-of-care responsibility with us.


“As we transfer that responsibility, we are going to be looking at-all those quality-of-life parameters to make sure that patients are getting the chemotherapy they need for their disease; that their overall survival is where it should be; that they’re not experiencing excessive toxicity of drugs; and that they have 24/7 access to care when they are experiencing the typical complications of chemotherapy treatment.”



What are your expectations for this initiative? 

“We expect quality to improve and safety to improve, and we believe cost will certainly be impacted, but in the right way. If the medical cost trend stays flat, I think that would be an important point for everyone considering how fast medical costs have been rising in oncology.”



What should oncologists and practice managers do to prepare for payment changes like your episode-of-care program?

“First and foremost, they should be thinking about how the current system is failing. It’s dysfunctional. What we want to do is to make oncologists the ‘captains of care’ again and put them in control so that there is less administrative burden to them and less insurance interference.


“But to do that, they have to take on responsibility, not just for episodes in terms of coming to the office or the hospital, but the whole continuum of care for that patient. At the same time, they must take on the responsibility of their reimbursement coming from a single-fee or bundled-payment approach. That’s a shift for some. They have to be prepared to make that shift. That’s the most important part.


“And then, they must be able to learn with us as we go along and communicate openly and honestly so that we make sure that patient care absolutely improves every step of the way. We must be very transparent about how these arrangements work, and make sure there is a partnership and a collaboration that puts the patient first, always.”

Sunday, March 08, 2015

I’m trying to learn as much as I can about the Centers for Medicare & Medicaid Services’ (CMS’) plans for a new pay for cancer care. So naturally I wanted to speak with Ted Okon, Executive Director of the Community Oncology Alliance (COA), which has been pushing for delivery and payment reform in cancer care for years.

COA Executive Director Ted Okon


We talked just a few days before COA announced its Oncology Medical Home pilot, and I was interested to hear him say that COA and CMS have similar ideas of what the future should look like.


Here’s an edited transcript of our conversation--you can also listen to a podcast of a portion of our conversation in the iPad edition of OT’s April 10 issue.


To set the stage for our conversation, please summarize how the Oncology Care Model will work.

Ted Okon:  “First of all, it’s important to understand that this is a model that operates on top of Medicare’s current reimbursement system for cancer care. Basically, there are two components to it. One is that it starts out by paying them for a care coordination or care management fee that is tied to six-month episodes of chemotherapy. That involves a number of things that practices have to do, but basically, there would be a reimbursement for what the Center for Medicare & Medicaid Innovation [CMMI] believes is a higher level of care coordination or care management.


“The second piece of the payment is a performance fee, which is based on hitting certain quality measures and actually achieving savings for Medicare that is, again, tied to these six-month bundles of chemotherapy. When a patient is receiving chemo during that period of time, the practice is getting reimbursed in the regular way and receives the care management fee, and, after two years, possibly receives a performance fee if they meet certain quality measures and they save money.”



Overall, what do you think of the Oncology Care Model concept? And do you think it will be attractive to community oncology practices? 

“First of all, it’s definitely a step in the right direction. CMMI designed something that really is an oncology medical home, but they didn’t call it that. The idea of paying a care coordination or management fee and also having a performance fee that is based on quality and then on cost is very much along the lines of what the COA model for community cancer care.


“The problem is, when you dig down into it, it gives you a little pause. COA had a board meeting and there were a lot of concerns raised by practices. One of the biggest concerns is that the performance fee is really more based on gain-sharing than shared savings.


“CMMI talks about shared savings, but true shared savings is when you are benchmarking your practice against other similar practices either in the region or across the nation. Gain-sharing is when you’re benchmarked against yourself.  The problem is that gain-sharing is not sustainable. You cannot have a practice that’s doing well and expect it to do better the next year and even better the next year after that (to qualify for performance bonuses.) And even though we told CMMI over and over and over again that gain-sharing was not sustainable, that is what they are referring to when they talk about shared savings. So that’s a big problem.


“The other thing that is a problem is what happens if, after the first two years, a practice doesn’t achieve savings and their costs are actually higher than expected? In order to stay in the program, they either have to pay back the difference or they are no longer eligible to receive the care management fee. And that’s really tough.


“I’m a little concerned about what this really does for patient care. What happens when a new therapy comes out that is so revolutionary and immediately becomes the standard of care, but is higher priced? Does the practice not use that? Or do they do what they should do--use the new therapy--and get bounced out of the program? So I think there are some big problems with this.


“Overall, I think it is a step in the right direction. I commend CMMI. They listened. We had a lot of physicians involved. They talked with us, they met with us. But I think they put something out that’s not totally formed yet and has some inherent problems. As a result, I think you may get some practices that will sign up to put a letter of intent in, but I’m not sure what’s going to happen when practices have to put in the application. We’ll see. We need more detail from CMMI.”



CMS hopes that many private payers will also adopt the Oncology Care Model so that practices will have a critical mass of their patients covered by the same payment methodology. Do you think this is likely to happen?

“It’s going to be interesting. When the model came out, I actually had emails from a number of payers, asking what we thought about it and what COA was going to do. I would imagine that a number of payers would actually sign the letter of intent, at least. Then I think it’s going to be a little bit of a cat-and-mouse game, if you will, for the payers to see whether providers are going to sign up and for the providers to see whether the payers will sign up. Stay tuned, and we need to see how this plays out.”



What should oncologists and practice managers be doing right now to prepare for payment reform?

“You know, I believe that what they should be doing is really following the basic tenets of the oncology medical home. And I don’t mean this to be self-serving from the standpoint of what we’re doing at COA. We are a non-profit. We don’t sell anything, and we don’t have a commercial interest.


“We have over 1,500 oncologists now that are using the patient satisfaction survey, which is basically a modification of the Consumer Assessment of Healthcare Providers and Systems Survey for Cancer Care (CAHPS) survey, and we’re working with CAHPS now on that.


“There have actually been over 35,000 completed patient satisfaction surveys in the field. This is not a commercial because people can go to the COA Oncology Medical Home website and use the survey without paying a thing. The survey allows them to benchmark not only within their practice, physician against physician, but also benchmark their practice against other practices. And as the database grows, that becomes meaningful.


“So I think practices should think about doing things like patient satisfaction surveys and measuring quality and thinking about transforming their practices. As an example, the seven COME HOME practices in Dr. (Barbara) McAneny’s CMMI grant pilot have shown some amazing results because those practices are transforming themselves.


“I don’t care whether you’re a two-physician practice or an 180-physician practice, you should start thinking about measuring quality, start thinking about the tenets of process change to become an oncology medical home, and transform yourself. And if you do that, you will be ready for any payment reform.” 

Tuesday, February 24, 2015



The work that Community Oncology Alliance has done to create an oncology medical home (OMH) model is getting its real-world test.


Ten practices are participating in a pilot of an accreditation program developed by cancer care organizations, advocacy organizations, insurers, and the Commission on Cancer. The practices are:


   Austin Cancer Center, Austin, Texas

   Center for Cancer and Blood Disorders, Ft. Worth, Texas

   Dayton Physicians Network, Dayton, Ohio

   Hematology Oncology Associates of Central New York, East Syracuse, N.Y.

   Maine Center for Cancer Medicine, Portland, Maine

   New Mexico Oncology Hematology, Albuquerque, New Mexico

   Northwest Georgia Oncology Centers, Marietta, Georgia

   Oncology Hematology Associates of Springfield, Springfield, Missouri

   Oncology Hematology Care, Cincinnati, Ohio

   Space Coast Cancer Center, Titusville, Florida.


“The OMH model provides enhanced patient communications, greater coordination amongst care providers, and increased responsiveness to patient needs,” Daniel P. McKellar, MD, CoC chair and executive committee chair, said in a press release. “The five summary categories of care -- patient engagement, expanded access, evidence-based medicine, comprehensive team-based care, and quality improvement -- are the basis for practice accreditation.”


The pilot is important because it includes several oncology practices that have been at the forefront of searching for better ways to deliver and pay for cancer care.


Seven of those practices are participating in the three-year COME HOME oncology medical home pilot under contract with the federal Center for Medicare & Medicaid Innovation (CMMI). Barbara McEneny, MD, CEO of New Mexico Cancer Center and founder of Innovative Oncology Business Solutions Inc., received a $19.8 million CMMI grant to conduct the seven-practice test of that medical home model.


The list also includes two practices in United Healthcare’s payment innovation pilot that reduced cancer care costs by more than 34 percent.


Wednesday, February 18, 2015

While waiting for tomorrow’s webinar from the Centers for Medicare and Medicaid Innovation Center (12 noon Eastern) introducing CMS’s Oncology Care Model (OCM) as a new way to pay for cancer care, I asked several people I respect to share their initial impressions. 


Oncology practices participating in the new plan will receive a $160 per-patient per-month payment and the opportunity to receive performance bonuses on top of Medicare fee-for-service rates. In return, they must provide high-value services including patient navigation, care planning, 24/7 patient access to a clinician, and the use of data for continuous quality improvement. Check out this fact sheet and these FAQs for details known as of today.


CMS intends to launch the plan in 2016, starting with practices that, through an application process, convince CMS they can meet the requirements. Oncology practices that wish to apply must submit letters of interest by April 23; applications are due by June18.


We will all be learning more about this new pay program in the weeks and months ahead, but here are first thoughts:


 Al B. Benson III, MD, Associate Director for Clinical Investigations, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago:  “I would agree with the American Society of Clinical Oncology that this is a fee-for-service model and that what is needed are more innovative approaches to address comprehensive cancer care delivery that best meets the needs of individual patients. ASCO has suggested some alternative models. 


“It is commendable that OCM is employing the IOM Care Management Plan and that treatment should conform to that recommended in national clinical guidelines. One would hope that a financial incentive model will not compromise clinician-patient choice of appropriate therapies and that patients will be fully informed as to treatments based on recognized guidelines. Models such as these should work to assess patient-reported outcomes and ascertain what services are critical to an individual’s overall cancer care incorporating an extensive range of services such as dietary intervention, genetic counseling, financial services, psychosocial support services, home care, and transportation as some important examples.


“Any economic or reimbursement model would need to have the flexibility to adjust for the variability of services, extending beyond drug treatment, reflecting the needs of each individual, and the out-of-pocket costs incurred by the patient. Encouraging patient participation in clinical trials should be an essential component of any model as well as reduction in administrative burdens, which increasingly are both costly and eroding the office time that would be best spent on the actual delivery of care to patients.


“In addition, the OCM model focuses on the physician office setting. While important, there is a growing trend to deliver cancer care in the hospital outpatient department – a trend that deserves attention for multiple reasons including possible limitations to access because of travel, increasing cost of care in the hospital versus the office setting and whether the ability to deliver high-value, quality care that is comprehensive can be improved in the hospital setting.”


 Barry Brooks, MD, Chair, US Oncology Pharmacy and Therapeutics Committee, and partner, Texas Oncology, Dallas:  Briefly, I think the per-patient management fee of $160/month is on the modest side for the case-management effort required, but candidly, it is more than I thought we might be offered. Benchmarking a US Oncology practice against itself for performance payment seems to punish us for our parsimony and stewardship over the last eight to nine years of clinical pathway development. We practice a disciplined, evidence-based form of oncology that is very cost-effective and we do not have as much room to shave costs as practices that have not yet embraced pathways. These latter practices could decrease their oncology spend by a much larger percent than we can because they have not harvested the “low-hanging fruit” available through clinical pathways and focusing on avoiding hospital admissions and ER visits.


“Another concern I have is that there is no mechanism to deal with costly immuno-oncology and targeted drugs that are currently flooding the market. Cancer care is going to be very expensive in the next three years -- more effective, but much more expensive. If CMS were to measure the cost of our treatment of lung cancer in 2014 versus that of treating the same patient in 2016, the cost could be up to 10 times greater even in a strict evidence-based world because of the costs associated with drugs like nivolumab.


“Bottom line is we are very excited to potentially be able to pilot our Innovent oncology model in a CMS project, but I fear that there can be no realistic expectation that anyone can achieve performance payments unless the model is adjusted for some of the factors mentioned above.”


 Patrick Cobb, MD, an oncologist/hematologist at St. Vincent Frontier Cancer Center in Billings, MT:  “I think it’s good that CMS is recognizing the value of multiple services that oncologists have provided to our patients, services that have not been reimbursed in the past.


“Most oncologists already provide most of the services in the list, so I don’t think it will be difficult for practices to participate. Usually problems arise when it’s time to report the data, and I hope CMS will make that process easy.


“Provider-based practices like ours that are aligned with a hospital can’t participate in this program, and that excludes a large portion of the cancer delivery system.


“I’m a bit skeptical that this program will decrease the overall costs of caring for cancer patients.  I think we can save some money by trying to keep patients out of the emergency room or the hospital, but progress in cancer treatment often includes adding newer drugs that are usually very expensive. Oncologists have no control over what pharmaceutical companies charge for these new agents.”


 Kathy Lokay, President and CEO, Via Oncology:

   “I really like the $160 per patient per month during each six-month episode and that CMS didn’t cap it at two episodes.

    “I’m concerned, though, about the volume and types of quality reporting measures (total cost of care and patient share of it, prognosis/expected response to treatment, lots of self-reported measures that today are only samples for Quality Oncology Practice Initiative purposes). Will they set quality targets or expect x% year-over-year improvement? Also, I will want to see how the gainshare would be reduced if you didn’t hit your quality measures.

    "Finally, lots and lots of questions remain about how the targets will be set and updated--the devil’s in the details here! And how do you stop folks from withholding certain care because it’s too expensive for their target? It’s hard to attest care concordant with guidelines when you don’t have a service to attest to (e.g., no neoadjuvant therapy to avoid including surgery costs; no radiation for bone mets, etc.).”


 Neal J. Meropol, MD, Chief, Division of Hematology and Oncology, University Hospitals Case Medical Center & Case Western Reserve University, Cleveland: “The time is ripe for payment reforms that reward coordination of care and better align financial incentives with high quality care and patient outcomes. The CMS program is an initial step in the right direction, but there is a long way to go to optimize how we pay for oncology care in the United States.”


 Lawrence Shulman, MD, Chief of Staff, Senior VP for Medical Affairs and Director, Center for Global Cancer Medicine, Dana-Farber Cancer Institute, Boston:  “In theory this is a good idea. I think we need to get to accepted pathways for disease treatment, but this might be a good first step.”



 Mark A. Sitarik, MD, Medical Director, Technology, McKesson Specialty Health, and partner, Rocky Mountain Cancer Centers, Boulder: “I think the concept is a good starting place. The proverbial devil will be in the details:

    Will the incentive payments be adequate to offset the added reporting requirements?

    How much of the reporting can be automated?

    What will the criteria be used to decide if a good episode of care was delivered?

    How many of those criteria will actually be under my control?

    What does payment after the episode mean? A week? A month? A year? After an audit?

“I think in general oncologists want to be reimbursed for the intellectual work that they do. I applaud CMS’ step in this direction. The challenge will be to implement this paradigm shift in a way that will not break the ability of providers to deliver care to our patients in need.


“I suspect that it will require climbing up and sliding down the learning curve a few times for all of the stakeholders before a functional system is fully developed and implemented. It will likely require a great deal of flexibility on the part of all parties involved.”

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About the Author

Lola Butcher
LOLA BUTCHER, MPA, MA, an award-winning Contributing Writer for Oncology Times, writes about health policy and business trends. She is a frequent contributor to Hospitals & Health Networks, Modern Physician, Neurology Today, and other health care trade publications. This blog was recently recognized with an APEX Award for Publication Excellence.