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Practice Matters
News about health policy and practice management issues of importance to oncologists
Sunday, August 24, 2014

If you have not been following the conversation about bundled payments for cancer care, it is time to get up to speed. A consensus that bundled payments is the best payment reform strategy is emerging, and we will see many pilot and demonstration projects starting soon.


The Centers for Medicare & Medicaid Services has been experimenting with bundled payments for orthopedic and cardiac procedures for years and it expanded the concept to include more than 40 medical conditions when the Bundled Payments for Care Improvement initiative launched last year. Oncology services are not included yet, but CMS is definitely planning to give bundled payments for cancer care a try.


At a webinar last week, Patrick Conway, MD, chief medical officer for CMS, and Erin Smith, CMS’ point person for new payment methods for specialty care, shared CMS’ current thinking about a new oncology care model. Scroll down to slide 11 to see the nitty-gritty details.


In another presentation, Ezekiel Emanuel, MD, PhD, chair of medical ethics and health policy at the University of Pennsylvania, reported that a consortium of oncologists, payers, patient groups, and policymakers convened by the Center for American Progress (CAP), where he is a senior fellow, is enthusiastic about bundled payments for cancer care. That said, I got the impression that CAP and CMS are working toward the same goal, but have diverging ideas about how to get there.


Members of the CAP consortium are planning to publish a recommended model and guiding principles and encourage a multi-payer demonstration, Emanuel said.


To date, the consortium has agreed that:

·    Bundled payments should start with high prevalence cancers, specifically metastatic non-small-cell lung cancer and adjuvant and metastatic colon cancer.

·    Both private health plans and government payers should participate in a bundled-payment demonstration so that oncology practices have enough patients covered by the new payment system to make it worth their participation.

·    Payment episodes should be based on the total cost of care (meaning everything from drugs to hospital inpatient care.)

·    The oncologist should be the “accountable” provider, as opposed to a hospital, even if a hospital employs the oncologist.

·    The financial risk to oncology practices should be phased in over time to give practices the opportunity to make the changes necessary to succeed with bundled payments.

·    All payers and providers should use a standardized set of meaningful quality measures. To see what CAP is thinking, scroll down to slides 11-13 of Emanuel’s presentation to see examples of the quality measures its members have in mind.


Bundled payments—is this the right idea for payment reform in oncology? Let me hear what you think!


Sunday, August 17, 2014

If you want to check out what the federal government is about to reveal about your financial doings, the time is now.


On Sept. 30, the Centers for Medicare & Medicaid Services will unveil the payments and other “transfers of value” from the medical industry to physicians and hospitals through its Open Payments initiative.


To check out the accuracy of the government’s information, you may want to register in CMS’ Enterprise Portal—as quickly as possible. The review and dispute period ends Sept. 8.


If you’re thinking “of course the information will be accurate,” remember that the Department of Health and Human Services has had some challenges with technology lately. In fact, its Open Payments website recently got confused between David E. Mann, MD, a retired electrophysiologist in Kentucky, and David E. Mann, MD, an oncologist in Florida, prompting CMS to temporarily suspend registration of the Open Payments so it could figure out who took money from whom. Registration resumed on Friday.


It is enough to make you grit your teeth in frustration, but there is a reason and another and another that the public needs to know who is taking money from pharmaceutical and medical device companies.






Wednesday, August 06, 2014

OT readers have been watching Patrick Soon-Shiong, MD, founder of Abraxis Bioscience (see here, here, here, here, here, here and here), for years, so you may think of him as the surgeon who developed albumin-bound paclitaxel. But he is also chairman of the Chan Soon-Shiong Family Foundation and chairman and CEO of the Chan Soon-Shiong Institute for Advanced Health, National LambdaRail, the Healthcare Transformation Institute and NantHealth, minority owner of the Los Angeles Lakers and Forbes’ pick as the wealthiest American in the healthcare industry.


And, as of this month, he is working for Providence Health & Services, a huge healthcare system on the West Coast, in the post of global director for cancer services and bioinformatics.


Yes, he needed the job -- not for the money, but for the opportunity to fulfill his vision for redefining cancer care through genomic medicine. In an interview with Modern Healthcare, Soon-Shiong said: “With Providence, there's an opportunity to take one of the largest healthcare systems on the West Coast, with 25,000 new diagnoses of cancer patients each year and 100,000 cancer patients across five different states, and institute this whole new paradigm of cancer care that is evidence-based and genomic-driven.”  


The Chan Soon-Shiong Institute of Molecular Medicine is partnering with Providence to create the country’s first clinical genomic network for whole genomic sequencing. According to a news release from Providence:

“Dr. Soon-Shiong’s recent execution of rapid analysis of more than 10,000 tumor and germline whole exomes or genomes, representing more than 6,000 patients across 20 different tumor types, demonstrated that the molecular signature of a cancer patient is independent of the anatomical tumor type.


“These findings are in stark contrast to widely held medical assumptions. These findings have the ability to vastly improve treatment recommendations because they suggest that a hypothetical breast cancer patient could potentially have more in common with a lung cancer patient than another person with the same ‘type’ of cancer.”

Wednesday, July 09, 2014

One of the early pilot programs for a new way to pay for cancer care just released its results. And my reaction is “Wow!” and “Huh?”


The results of UnitedHealthcare’s pilot with five oncology practices is now available online as an Early Release article in the Journal of Oncology Practice. (For OT’s previous coverage, click here and scroll down to “United's 19 Categories, 20 Performance Measures” heading and here.)


The “wow” is this: The use of a bundled-payment system for cancer care yielded a 34 percent reduction in predicted total medical cost without harming patient outcomes.


The “huh?” is this: The key feature of the experimental payment system was to reduce the connection between treatment selection and physician income, on the idea that this would reduce chemotherapy costs. However, chemotherapy drug costs were 179 percent higher than predicted based on a comparison with similar practices.


Despite spending $13 million more on drugs than would have been expected—and UnitedHealthcare was actually expecting to reduce its drug bill—the pilot still saved $33 million on the cost of treating 810 patients during the three-year pilot.


Lee Newcomer, MD, senior vice president for oncology, genetics and women’s health at UnitedHealthcare, and his co-authors (Bruce Gould, MD; Ray D. Page, DO, PhD; Sheila A. Donelan, MS; and Monica Perkins, PhD) say the study data does not allow them to fully understand how the costs savings were achieved—or why the drug costs were so much higher than expected. They do know that hospitalization use and use of therapeutic radiology both decreased, but whether one or both is the magic bullet is not clear.


The authors say they do think that simply getting together to share information was important: “Collaboration was an essential element to the success of the pilot,” they write. “The data for the project were available to all participants. Variation was explicitly discussed as an opportunity for improvement and not a failure of health care delivery. Problem solving involved the participation of physicians, the medical group business executives, nursing staff, and payer staff.”

Tuesday, July 08, 2014

New Mexico Cancer Center (NMCC), one of the pioneers of the oncology medical home model, will be featured in a MEDTalk: Reinventing Patient-Centered Cancer Care webcast starting at 10:30 am ET on Wednesday.   


Everybody interested in the future of cancer care delivery and payment should be tracking what NMCC and the other practices in the COME HOME program are doing. The Centers for Medicare & Medicaid Innovation (CMMI) awarded Barbara McAneny, MD, NMCC CEO, a $20 million grant to test the oncology medical home model because CMS thinks that might be an alternative payment approach that makes cancer care financially sustainable.


Check out this Health Affairs blog post to get a sneak peek on how it’s going. Some of the top health care policy people in the U.S. -- Darshak Sanghavi, MD; Mark McClellan, MD; and Kavita Patel, MD -- all of Brookings Institution, write a brief case study that includes this troubling observation: “NMCC currently receives approximately $70,000 per month from the CMMI grant and has not yet identified a clear strategy to sustain the delivery reforms in the COME HOME care model past the end of the grant (July 2015). As for payment reform options, NMCC has been unable to contract as part of a comprehensive ACO due to local health care market conditions.”


But it also includes this fascinating observation:  “NMCC could potentially use the medical home approach with risk sharing (described above) as a first, interim step toward a bundled payment system, NMCC’s long-term preferred model.”


The “described above” is what you need to pay attention to. The blog post includes a table (see Table 2 about half-way down the post) that shows the level of financial risk to oncologists associated with four alternative cancer care payment approaches. Oncology medical home has minimal risk; bundled payments—identified as NMCC’s true goal—has high risk. That means NMCC is positioning itself to accept a flat rate—and guarantee certain quality standards—to treat a population of cancer patients.


If that is where cancer care is headed, will your practice be ready?

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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.