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Practice Matters
News about health policy and practice management issues of importance to oncologists
Tuesday, October 21, 2014


As I was reporting the articles for the OT series, “UNINTENDED CONSEQUENCES: How Government Policies Have Increased the Cost of Cancer Care,” I was eagerly awaiting the release of the Community Oncology Alliance’s (COA) annual update of how these policies have affected physician-owned cancer care practices.


The report, released today, shows that 25 cancer treatment facilities closed and 75 physician-owned oncology practices were acquired by or affiliated with hospitals since COA’s last report in June 2013.


“It required close to 50 years to build this country’s cancer care delivery system, but misguided policy in Washington is destroying it at an alarming pace,” COA Vice President Jeffrey Vacirca, MD, CEO at North Shore Hematology Oncology Associates, said in a news release. “Hospitals are contributing to the escalating cost of cancer care — where the same cancer care is more costly for patients and their insurers. To truly stand up for cancer patients is to stop this destruction, or we will lose the war on cancer.”


Since COA started tracking eight years ago, 313 cancer treatment facilities have closed and 544 have joined hospitals. Whether this is good or bad depends on one’s perspective. The final installment of the “UNINTENDED CONSEQUENCES” series, expected to be published in the Nov. 25 issue of OT, examines this from various viewpoints.


One new data point from this year’s COA report:  Nearly 75 percent of the private practices that have been acquired or affiliated with hospitals in the past two years have been with hospitals that are eligible for 340B drug discount pricing. Click here to see the OT article about this phenomenon.


COA says that, in addition to the 340B program, the consolidation has been fueled by insufficient Medicare reimbursement and the ongoing sequester cut to cancer drugs. Click here to see the OT article on that topic.


Community Oncology Alliance

Sunday, October 19, 2014



BOSTON -- Several takeaways from the American Society of Clinical Oncology’s third Quality Care Symposium, which wrapped up here yesterday afternoon:

·    Frustration with electronic health record systems is increasing. One of the major drivers for EHR technology is that, at the theoretical level, it should improve the quality of patient care. Representatives from four major EHR vendors shared their perspective of how this works, but I got the sense that the audience wasn’t with them. Douglas Blayney, MD, chair of the session, asked why smartphones can be so easy to use when EHRs are so clunky. Barry Brooks, MD, said some EHRs are a patient-safety hazard. The vendors said they are working it, but nobody pushed back against the criticisms.

·    Value (quality divided by cost) is not always intuitive. Although academic medical centers are considered the most expensive—and best quality—healthcare providers, Christine Marie Veenstra, MD, presented results from a study that found that the cost of care for Stage II and Stage III colon cancer patients was not more expensive at an academic hospital than a community hospital. And, by the way, overall survival time was the same, regardless of academic or community hospital.

·    There are so many standards—and yet not enough. The importance of standardization in cancer care has been a drumbeat in recent years, but Monika Krzyzanowska, MD, MPH, made an excellent presentation on the lack of standards for oral therapies that are sent home with patients. Who knows if the medicines are taken as directed? (I noticed at least three abstracts that dealt with this topic as well, and I’m going to wade into them for an upcoming article for OT.)

·    Big data to the rescue? After seeing presentations about PCORnet, the Integrated Cancer Information and Surveillance System, the National Cancer Institute’s Surveillance, Epidemiology and End Results program, the Commission on Cancer’s National Cancer Database, and CancerLinQ, I was so dizzy I can’t remember exactly what any of them do. However, the excitement by each of the presenters made a big impression on me; each believes that data gathered, analyzed, and shared in new ways will lead to cancer treatment breakthroughs heretofore unimaginable. This was also the only session I saw in which ASCO’s minute-by-minute schedule went off the rails, leaving ASCO President Peter Yu, MD, with exactly zero minutes to give his update on CancerLinQ. (No worries--the session was extended into the break.)


If you are eager to attend the next Quality Care Symposium, so am I. But we will have to wait a while: There won’t be one in 2015; the next one will be scheduled in early 2016.

Saturday, October 18, 2014


BOSTON -- The first session of the American Society of Clinical Oncology Quality Care Symposium was devoted to presentations on overtreatment in cancer care, and the main takeaway is that oncologists recognize overtreatment is rampant but they don’t know what to do about it.

 Lisa Hicks, MD, from St. Michael’s Hospital at the University of Ontario, listed several factors that promote overutilization, including the medical culture that says more tests and treatments are better; defensive medicine; financial incentives to do more; the rapid change in science; the patient culture that every problem can be solved; and direct-to-consumer marketing.

The idea behind the “Choosing Wisely” campaign (see here and here and here and here and here and here) is to give physicians and patients straightforward ideas about how to avoid inappropriate utilization.


So are oncologists using the “Choosing Wisely” advice? Some are, some aren’t, according to the results of a study presented here. Overall adherence to ASCO’s initial Top 5 list, issued in 2012, of things that oncologists and their patients should question before proceeding varied from 51 percent to 78 percent.

 Karma Kreizenbeck, project director at Hutchinson Institute for Cancer Outcomes Research at Fred Hutchinson Cancer Research Center, presented the study, which used a database that linked the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) records for about 24,000 cancer patients diagnosed in western Washington state between 2007 and 2013 with enrollment and claims data from Premera Blue Cross.


To refresh your memory, here are those initial Top 5 items:

·    No anticancer therapy for patients with advanced cancer and poor performance status;

·    No PET, CT, and bone scans in early prostate cancer;  

·    No PET, CT, or radionuclide bone scans in early breast cancer;

·    No biomarkers or advanced imaging following breast cancer treated for cure; and

·    No colony-stimulating factors for chemotherapy with less than a 20 percent risk for febrile neutropenia.


Kreizenbeck and her colleagues found:

·    59 percent adherence to the measure “no chemotherapy or radiation for solid tumors in the last two months of life” for patients with advanced disease;

·    79 percent adherence to the measure “no PET, CT, and bone scans within two months of early prostate cancer diagnosis”;

·    97 percent adherence to the measure “no PET, CT, and bone scans within two months of early breast cancer” for patients with tumors in situ;

·    57 percent adherence to the measure “no PET, CT, bone scans, and tumor markers between two and 14 months after curative therapy for early breast cancer” for patients with localized tumors; and

·    83 percent  compliance to the measure “no colony-stimulating factors with 45 days of chemotherapy start for patients with breast, non-small-cell lung cancer and colorectal cancer who have less than a 20 percent risk for febrile neutropenia.”


Are these adherence rates good or bad? I’d love to hear what you think. Leave a comment here or tweet me at @lolabutcher.

Wednesday, October 15, 2014


More than 500 people are expected to attend the American Society of Clinical Oncology’s third Quality Care Symposium this week in Boston, and I am excited to be one of them.


The fact that this annual event is growing so quickly—more than 300 abstracts will be presented this year—highlights the rapid change in the way oncologists are thinking about their work.


Checking out the abstracts, I see a heavier emphasis on value—the intersection of cost and quality in cancer care—than in the previous two symposia. In fact, the opening session is titled “Choosing Wisely” and includes two presentations about overtreatment—a concept that almost no one talked about a few years ago. That session also features a sneak peek at adherence to ASCO’s first Choosing Wisely Top 5 list, which is something I have been wondering about. You can find out yourself by clicking into the abstract  or check back here, because I will be writing about this presentation on Friday.


Another session I’m eager to see: “Strategies to Utilize Electronic Health Records for Quality Improvement.” Many of you probably rolled your eyes when you read the title of this session. I’m sure the vendor representatives will enlighten us, but I’ll most interested to hear what Douglas Blayney, MD, says in his “Counterpoint to Vendors” comments.


I am also looking forward to “Quality Issues For Cancer Patients And Survivors With Multiple Chronic Conditions: Understanding The Patient's Perspective,” by Neeraj Arora, PhD, Program Director for Patient-centered Care Research at the National Cancer Institute. I met him at last year’s Quality Care Symposium and interviewed him for this OT article.


The other can’t-miss session for me is Saturday’s oral abstract breakout session on “Cost, Value, and Policy in Quality,” moderated by Lawrence Shulman, MD, who was a great help to me on this OT article. One of the presenters will be Lowell Schnipper, MD, who has chaired ASCO’s Cost of Cancer Care Task Force for many years.

(But oops… this event requires a ticket, which I failed to notice when I registered. Note to ticket scalpers: I will be lurking outside the meeting door waiting to make a deal.)


For those of you who cannot attend the Quality Care Symposium, what sessions do you wish you could see? Let me know, and I’ll check them out for you! Leave a comment here, or tweet me at @lolabutcher.

Thursday, October 02, 2014

I am not sure what to make of it, but I find it interesting that two cancer centers—Dana-Farber Cancer Institute and the University of Texas M.D. Anderson Cancer Center—received more than double the amount of research funding from manufacturers than any other teaching hospitals for the last five months of 2013.


That factoid comes courtesy of Modern Healthcare, which dug into the government’s new Open Payments database when it came online earlier this week.


The launch of Open Payments, established by the Physician Payments Sunshine Act, marks the first time that patients have been able to see who is giving money to their doctors and why. The first data release revealed payments totaling $3.5 billion to 546,000 physicians and 1,360 teaching hospitals between Aug. 1, 2013, and Dec. 31, 2013.


As with most big government initiatives involving computers, this one has not gone smoothly. In fact, lots of the payment data released this week had to be de-identified because the Centers for Medicaid & Medicare Services needs to verify its accuracy.


So it will take a while to get the bugs worked out, but Open Payments is a good move, in my opinion. We all know that the healthcare industry is rife with conflicts of interest, and anything that helps us understand and expose those is good.


Open Payments, in and of itself, does not highlight conflicts of interest—defined by the Institute of Medicine as “a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest.” It just shows who got money from whom. Most of the $3.5 billion that manufacturers shelled out to physicians over a five-month period is probably justifiable, but just knowing the huge amount of money in play puts everybody on notice that this is something we need to know more about.


How patients and others will use the information available via Open Payments remains to be seen. Check out this Health Affairs policy brief for a nice backgrounder and an explanation of why this is just the beginning of the information we need to know.

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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.