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Practice Matters
News about health policy and practice management issues of importance to oncologists
Monday, October 05, 2015


The American Society of Clinical Oncology issued a formal recommendation back in 2012 for the early use of palliative care for any patient being treated with metastatic cancer and/or a high symptom burden.  

At the Palliative Care in Oncology Symposium coming up later this week, ASCO and the American Academy of Hospice and Palliative Medicine (AAHPM) will issue guidance about what good primary palliative care looks like.


At a presscast today highlighting important abstracts to be presented at the symposium, Kathleen Bickel, MD, assistant professor of medicine at the White River Junction Veterans Medical Center, said the new guidance statement marks the first time that formal consensus-based recommendations have been made about the types of palliative care services that medical oncology practices should provide.


“Not all cancer patients have access to specialist palliative medicine and the small workforce of palliative care specialists is insufficient to meet the needs of all patients who would benefit from their services,” she said. “Thus, alternative care models are being sought.”


Bickel, who also works at the Geisel School of Medicine at Dartmouth, is the lead author of the study (Abstract 108). She worked with a 31-member multidisciplinary panel that included physicians, patient advocates, social workers, nurses, and nurse practitioners, to rank 966 different palliative care service items, grouped into nine domains, according to their importance and feasibility and whether the services were within the scope of medical oncology practice. 


Items that ranked highly in all three areas—importance, feasibility, and scope—were included in the definition of high-quality primary palliative care in oncology.


“We want to improve the palliative care already being delivered by oncology practices—what we are calling primary palliative care,” Dr. Bickel said.


I’ll be writing more about this after the symposium, but here’s a sneak peek at what got a thumbs-up from the panel:

·        Manage nausea and vomiting resistant to second-line treatment;

·        Determine the patient’s and family’s understanding of prognosis; and

·        Assess the need for hospice referral at the time of diagnosis of an incurable cancer.

Monday, September 28, 2015

Back in 2013, more than 100 chronic myeloid leukemia (CML) specialists from around the world signed on as coauthors to an article protesting the high cost of tyrosine kinase inhibitors.


The lead author—Hagop Kantarjian, MD, Professor and Chair of the Leukemia Department at the University of Texas MD Anderson Cancer Center—and colleagues recently used that same approach to bring a wide range of U.S. hematologists and oncologists aboard the campaign against unaffordable cancer treatments.


A commentary, “In Support of a Patient-Driven Initiative and Petition to lower the High Price of Cancer Drugs,” in the August issue of Mayo Clinic Proceedings was coauthored by 118 American cancer specialists, including some of the biggest names in the field.


The article reiterates seven specific solutions that Dr. Kantarjian and S. Vincent Rajkumar, MD, the Edward W. and Betty Knight Scripps Professor of Medicine in the Division of Hematology at the Mayo Clinic, put forth in the March issue of the same journal.


The new commentary lends encouragement to patient-driven movement advocating against the high costs of cancer drugs. It points specifically to an online petition drive on, which is being promoted on Facebook and Twitter (@StopHighRxCosts).


That’s just the idea Dr. Kantarjian told me about when I interviewed him for OT earlier this year: “If we can get a million signatures online, either through Twitter or Facebook, about patients who say ‘I protest high cancer drug prices because...’ and tell their stories, this will become a major story that will put pressure on drug companies,” he said. “And it will put pressure on our elected representatives to try to reduce high cancer drug prices or to make cancer drugs affordable to all patients.”


As of Sept. 28, more than 33,000 individuals had signed the petition.


“With proper support of these grassroots efforts, and proper use of that support downstream, it should be possible to focus the attention of pharmaceutical companies on this problem and to encourage our elected representatives to more effectively advocate for the interest of their most important constituents among the stakeholders in cancer—American cancer patients,” the Mayo Clinic Proceedings authors said.





Sunday, September 20, 2015

Controversy about the government’s 340B drug discount program continues, but that has not slowed expansion, according to a new study released by the Community Oncology Alliance (COA.)


The 340B Drug Pricing Program, administered by the Health Resources and Services Administration (HRSA), allows hospitals that serve a large number of low-income patients and some other types of providers to buy outpatient drugs at deep discounts. 340B hospitals can charge whatever they want for the drugs they purchase at discounted prices, which creates a financial incentive to grow their cancer care service lines.


The 340B program has been expanded repeatedly, making more cancer care providers eligible for the discount program—but physician-owned cancer centers are not eligible for the discounts. That is why COA and others say the continuing expansion of the program creates an unfair playing field.


“The 340B program is a critical safety net for patients in need in the hospital setting,” COA President Bruce Gould, MD, a community oncologist with the Northwest Georgia Oncology Centers in Marietta, Georgia,  said in a news release. “However, I am shocked at how big the program is, as revealed by this new study, and am very concerned about the higher costs of cancer treatment for patients and Medicare in 340B sites.”


In an interview with the American Journal of Managed Care, Gould said the 340B program has prompted the migration of cancer care to hospitals. About half of the approximately 130 oncologists practicing in the Atlanta metro area work at hospitals with 340B drug pricing.

“We are competing based on who has the deepest pockets,” he said. “Obviously, in this case, the hospital-based group has deeper pockets—they can hire my employees and doctors by providing them with better salaries.”


The Berkeley Research Group, commissioned by COA, found that:

·    The average reimbursement for outpatient oncology drugs is 52 percent higher in 340B hospitals than in community cancer clinics on a per-Medicare beneficiary basis; and

·    340B hospitals saw a 123 percent increase in total Medicare Part B reimbursement for oncology drugs between 2010 and 2013. By contrast, non-340B hospitals saw a 31 percent increase during that time, and community oncology clinics experienced a five percent decrease.


“This study adds to the findings from GAO and others that 340B has not only grown way beyond the original congressional intent but also that 340B hospitals are costing Medicare and the seniors they treat more for cancer care,” said COA’s Executive Director, Ted Okon.  


He was referring to GAO’s June report, which concluded: “Congress should consider eliminating the incentive to prescribe more drugs or more expensive drugs than necessary to treat Medicare Part B beneficiaries at 340B hospitals.”


The GAO is an independent government agency, and it acknowledged that HRSA’s parent, the Department of Health and Human Services, did not support its conclusions.


To read a vehement defense of the 340B program, check out, published by 340B Health, formerly known as Safety Net Hospitals for Pharmaceutical Access.


To learn why COA and others oppose the continuing growth of the 340B program, follow 340bReform at @AIR340B.


For a less impassioned review of the topic, read this May 2015 report to Congress written by the Medicare Payment Advisory Commission.

Saturday, September 19, 2015


Cancer care facilities are providing more supportive services for patients, but payment for the services is not covering the expense, according to the newly released results from the 2015 Trends in Cancer Programs survey conducted by the Association of Community Cancer Centers.


A large majority—65 percent—of survey respondents cited lack of reimbursement for supportive care services as their biggest challenge.


Most oncology practices are adding services to improve the value of care for their patients. Survey results show that 89 percent of respondents offer nurse navigation; 88 percent offer psychological counseling; 87 percent offer survivorship care; and 87 percent offer palliative care.    


“As these programs strive to provide more patient-centered services, knowing the positive effect these services have on improving patient health outcomes, reimbursement has become a bigger challenge,” ACCC President Steven L. D’Amato, said in a press release. “Payers will need to recognize the efforts from cancer programs to better communicate the value of these services.”


The survey, now in its sixth year, is a joint project of ACCC and Lilly Oncology.


Other noteworthy survey findings:

·    Many respondents are worried about their ability to meet Commission on Cancer patient-centered standards that went into effect this year. More than half (51%) are concerned about meeting Standard 3.3 for survivorship care;

·    Quality and compliance initiatives related to oral drugs are on the upswing, with 53 percent of respondents offering these programs in 2015, up from 34 percent the previous year. Most of the programs focus on educating patients about issues related to oral treatments, and 77 percent proactively reach out to patients to make sure they are complying with medication orders; and

·    As the number of uninsured patients declines, the number of under-insured patients increases. More than half of respondents reported an increase in the number of under-insured patients, and 44 percent said patients unable to afford treatment is one of their biggest challenges.

Friday, September 18, 2015

Two cancer centers—Memorial Sloan Kettering Cancer Center (MSKCC) West Harrison (NY), and St. Charles Cancer Center in Bend, Oregon—won first and second place, respectively, in Modern Healthcare’s 30th Annual Design Awards competition.


In announcing the winners, judge Rulon Stacey, a former health system CEO who chairs the Malcolm Baldrige National Quality Award board of overseers, said other health care sectors should follow the example set by oncology: “Oncology has uniquely understood for a long time the magnitude of what they’re doing and how healing is more than just chemotherapy. The rest of the industry has to find out what they can learn from them.


MSKCC received the Gold Award for its new 102,000-square-foot suburban outpost, which opened last October. Noteworthy elements, the judges said, include:

       A prominent staircase in the middle of the lobby that encourages staff and others to use the stairs rather than elevators;

       A chemotherapy suit with infusion chairs that have outdoor views and a direct line of sight to the nurses’ station. Technology allows patients to order food, call a nurse, select a movie; and control their own lighting; and

       An energy-efficient design that includes recycled and low chemical-emission materials, water efficiency, and access to public transportation.


And here’s a neat idea that any cancer center could borrow. The facility displays photographic art—supplied by staff members—that changes each quarter so patients see new images over the course of their treatment.


“Patients repeatedly go back,” said Mary Frazier, a principal with the EwingCole design firm. “This gives patients a feeling of progress.”


The Silver Award went to St. Charles Cancer Center, which opened in August 2014. The 24,705-square-foot outpatient center brings medical oncology and radiation oncology into the same facility, which makes life easier for patients and family members.


The center features floor-to-ceiling windows positioned to maximize views of a dormant volcano in a nearby state park, and when weather permits, patients can have treatments outdoors overlooking the Cascade Mountains.

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.