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Practice Matters
News about health policy and practice management issues of importance to oncologists
Wednesday, January 21, 2015


Seven cancer practices will begin submitting patient records to the first version of CancerLinQ, the “big data” platform that the American Society of Clinical Oncology is developing to guide oncologists in improving patient care.


When fully operational, CancerLinQ will analyze patient care data from electronic health records to provide clinical decision support that is pertinent to a patient’s unique constellation of personal and medical factors.


In a presscast today for reporters, ASCO announced that its wholly owned subsidiary, CancerLinQ LLC, has now teamed with SAP, described as one of the world’s largest software manufacturers, to use the SAP HANA platform to develop CancerLinQ. ASCO President Peter Paul Yu, MD, said ASCO has committed more than $10 million to the effort, although financial specifics were not revealed. Some of the funding has come from major donations.


The initial practices--called “vanguard practices”—which will provide patient records beginning later this year are:

   Inova Comprehensive Cancer & Research Institute;

   South Coast Centers for Cancer Care;

   New England Cancer specialists;

   Medical Oncology Hematology Consultants;

   Cancer Treatment Centers of America;

   Marin Cancer Care;

   Space Coast Cancer Center; and

   Michiana Hematology-Oncology


“We are participating in CancerLinQ and excited to do so because we think this will transform cancer care,” said Therese Mulvey, MD, Physician-in-Chief at South Coast Centers.


Another seven cancer centers have agreed to join subsequently, meaning than about 500,000 patients will be represented in the first version of CancerLinQ, according to information from the society.


As described in my earlier articles/posts in OT, ASCO has been working on CancerLinQ for many years; and in 2013, announced that its proof-of-principle trial had proved successful, leading to the decision to proceed with the ambitious project.

Wednesday, January 07, 2015

UnitedHealthcare, which started requiring prior authorization for all injectable chemotherapy in Florida last May, will expand that requirement nationally this summer.


While the move will likely irk oncology practices that rue the hassle of prior authorization, it will save some practices from the shock and disappointment of finding that the chemotherapy they have already provided is not going to be paid by the insurer.


In 2008, UnitedHealthcare became the first national insurer to tie coverage for chemotherapy drugs used in outpatient settings to compliance with the guidelines published in the National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium.


“Unfortunately, we still end up denying between $50 million and $60 million worth of chemotherapy every year because it didn’t match NCCN criteria,” said Lee Newcomer, MD, Senior Vice President for Oncology, Genetics and Women’s Health at UnitedHealthcare. “And that means the physician has treated someone and they’re holding the bag now for that expense.”


Denials account for about five percent of the chemotherapy provided to outpatients covered by UnitedHealthcare.


The new online prior authorization process requires an oncology practice to submit clinical information about a patient that allows acceptable treatment regimens to be identified. “We’re using the same NCCN rules that we’ve always used, but this process automates the selection of the regimen and makes it easier for physicians to know that they’re going to get coverage,” Newcomer said. “The physician won’t have to guess whether or not the regimen is NCCN-compliant.”


By collecting the patient information, the insurer is building a database that may shed light on the relative effectiveness of chemotherapy treatments.


“We will be putting 20,000 patients a year on prior-authorization protocols, where we will be collecting data about their specific clinical situation and the exact regimen that they’re being treated with,” he said. “I think that tool will allow us to start comparing drug regimens much more quickly than the episodes program.”


He was referring to a three-year pilot in which five oncology practices were paid on an episode-of-care basis for the care delivered to patients with certain types of cancer. The program, which has been extended for additional years and expanded to include another practice, did prove that the pay approach dramatically decreased the total costs of cancer care, although the number of patients treated during the pilot was insufficient to draw conclusions about which treatments worked best.

Saturday, December 20, 2014

The drumbeat calling for bundled payments for cancer care grew stronger this week when the Journal of Clinical Oncology published an editorial, “Payment for Cancer Care: Time for a New Prescription,” by Lowell Schnipper, MD, and Neal Meropol, MD, in which they promote the bundled payment framework put forth by the American Society of Clinical Oncology earlier this year and propose a randomized trial to see if it works:


It is likely that this level of evidence will be required as we seek to overhaul a system that is firmly entrenched among various stakeholders,” they write. “The complexity of organizing such an endeavor to test the outcomes (intended and unintended) of a bundled payment system is apparent: it will involve physicians, payers, and our patients across a variety of practice settings.”


Schnipper and Meropol then ask readers if they are serious about wanting a new payment system: “This can be accomplished. The question is whether the collective will exists to find a prescription for cure.”


The editorial was pegged to another article--“Did Changes in Drug Reimbursement After the Medicare Modernization Act Affect Chemotherapy Prescribing?”--in the same issue, a study by Mark Hornbrook and coauthors Jennifer Malin, Jane Weeks, Solomon Makgoeng, Nancy Keating, and Arnold Potosky) of 3,613 patients treated for colorectal cancer or lung cancer between 2003 and 2006.


The authors hypothesized that the changes in oncology drug reimbursement written into the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) would change physician prescribing behavior. The thinking behind that part of the MMA was that it would reduce Medicare’s cancer care costs, so it was a good question to ask.


Their analysis of data from the Cancer Care Outcomes Research Surveillance Consortium found that, in some cases, prescribing patterns did change after the MMA went into effect—but not in all. The authors concluded that the MMA did not have as much impact on prescribing patterns as the introduction of new drugs, new clinical evidence, and other factors.


Regardless of the MMA’s intent, the aggregate cost of cancer care has increased by up to 66 percent, since the law’s passage, despite a slight decrease in cancer incidence rates, the authors write:


“After passage of the MMA, independent community oncology practices saw substantial decreases in their revenues, which resulted in consolidation and acquisition by practices by hospitals, many of which are able to purchase chemotherapy drugs at discounted rates through the Federal 340B Program. Although the full impact of these changes is not known, the shift of chemotherapy from outpatient settings is associated with higher total costs for private payers.”


This suggests that tweaks to the fee-for-service system used to pay for cancer care are insufficient to curtail the rapidly rising costs. As Schnipper and Meropol argue, “The time is ripe to develop, test, and implement a prescription for change.”

Tuesday, December 09, 2014

The annual National Practice Benchmark survey findings—oncology’s version of the State of the Union address—appear in the November issue of Journal of Oncology Practice (subscription required), and they are not all bad.


Actually, some of the findings—based on practice performance in 2013—do seem depressing. But analysts Thomas Barr and Elaine Towle of Oncology Metrics say leading oncology practices have adapted to their straitened financial circumstances and are holding their own. And they do not forecast any major changes, good or bad, for those practices in the foreseeable future.


“The oncology health care ecology will remain a stable system with episodic, isolated, market-specific alterations, which though dramatic locally, will not materially affect the entire system,” they write in a JOP companion piece, “Oncology Practice Trends from the National Practice Benchmark.” 


Two lowlights of the survey findings include:

·    Practices report the lowest clinical productivity in the nine years the survey has been conducted. This was measured by established patient visits per full-time equivalent (FTE) staff. The authors suggest the low productivity stems from compliance requirements and electronic health record technology demands, both of which tend to require additional staff members.

·    Total operating costs and costs of drugs to the practice are both increasing.


On the other hand, Barr and Towle say the “shocks to the system” stemming from the decreases in drug revenue attributable to the Medicare Modernization Act have dissipated over time.


“All oncology delivery systems, including the practices delivering care, seem to have adjusted to the new environment,” they wrote. “In other words, the participating practices have found ways to stabilize their practices within a changing ecosystem.”


On a good note, the profit margin on drugs increased to almost 18 percent in 2013. The variability in margin in recent years makes it difficult to predict whether this will hold; Barr and Towle expect the 2014 margin will end up between 12 percent and 20 percent.


The purpose of the survey is to provide data that allow oncology practices to benchmark their performance against one another. An important caveat, however, is that the survey findings reflect the performance of only the most sophisticated oncology practices.


More than 900 practices and institutions across the country were invited to participate in the survey, but only 59 practices submitted usable responses. Survey authors say that respondents are “among the most competently managed and business savvy in the nation.” Thus, the performance of their practices may not be matched by more typically practices.


“Among survey participants, there is considerable variation in their overall business health, but taken together, these data support the premise that successful adaptation continues,” they said.

Wednesday, November 26, 2014

If you are dreading a rehash of the election results or your brother-in-law’s religious conversion or Aunt Sue’s gallbladder surgery, I offer another topic for your Thanksgiving Day conversation: myths and realities in cancer care.


In the October issue of Health Affairs, two economists--Dana Goldman and Tomas Philipson--offer a provocative Viewpoint called “Five Myths About Cancer Care in America.” 

·    Myth 1:  The war on cancer has been a failure;

·    Myth 2:  Detection, not treatment, accounts for most of the survival gains;

·    Myth 3:  Treatment costs are unsustainable;

·    Myth 4:  Cancer treatment at the end of life is of low value; and

·    Myth 5:  Supportive care is overused.


Access to the article requires a subscription, but this graphic highlights their arguments in a succinct way. And published a follow-up piece in which Philipson discusses the arguments and evidence presented in the original article.


The unconventional thinking might be easy to dismiss except for the fact that the myths list is published in Health Affairs (the world’s second-greatest journal after OT) and that the authors are health policy heavyweights.


Their piece must be read in conjunction with its companion Viewpoint, “Myths and Realities in Cancer Care: Another Point of View,” by Lee Newcomer, MD, vice president in oncology services for UnitedHealthcare. His observations are summarized in a UnitedHealthGroup press release.


Newcomer supports much of what Goldman and Philipson say, but he puts it in a different context. In his view, the war on cancer risks being lost to the high cost of health coverage, which is “projected to reach heights that are simply unsustainable for most American families.”


“Such an overwhelming burden will continue to undermine the progress made in developing new, more effective treatment and care for cancer patients,” he wrote. “There cannot be a celebration of discoveries if there is no way to pay for them.”


And now for that second piece of pie….

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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.