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Practice Matters
News about health policy and practice management issues of importance to oncologists
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….

Monday, November 17, 2014

The federal government estimates that nearly 16 million Americans will gain health care coverage by 2019 from the expansion of Medicaid, courtesy of the Affordable Care Act. But that does not guarantee that those individuals—or the 67.9 million individuals currently enrolled in Medicaid—will receive the same quality of cancer care available to patients with private insurance or Medicare coverage.

That disparity prompted the American Society of Clinical Oncology today to issue a policy statement calling for major Medicaid reform. The policy statement, published as a special article in the current issue of the Journal of Clinical Oncology, was announced in a presscast for journalists.

Speakers included ASCO President Peter Yu, MD, director of cancer research at Palo Alto Medical Foundation; policy statement co-authors—Michael Halpern, MD, associate professor at the University of Arizona Mel and Enid Zuckerman College of Public Health, and Blasé Polite, MD, assistant professor at the University of Chicago—and Shelley Fuld Nasso, chief executive officer of the National Coalition for Cancer Survivorship.

“As oncologists, we believe it is our responsibility to advocate for policies that expand access and improve the care of all people with cancer, regardless of financial means,” Yu said. “We also believe that no individual diagnosed with cancer should be without insurance that guarantees access to high-quality cancer care delivered by a cancer specialist.”


ASCO intends to use the statement to influence Medicaid policy at the federal and state levels.


About 20 percent of the U.S. population is currently enrolled in Medicaid, and an estimated 2.1 million Medicaid beneficiaries have had a cancer diagnosis, according to ASCO.


“There are at least 40,000 low-income Americans with a cancer diagnosis who would be eligible for Medicaid but who live in states that have not expanded Medicaid under the Affordable Care Act,” Halpern said. “These individuals have limited access to cancer care services.”


Additionally, Medicaid coverage rules vary by state—and also by whether an individual becomes eligible for Medicaid through the ACA’s expansion versus being eligible for the program previously—so the safety-net insurance program does not provide uniform coverage for certain services.


One barrier to appropriate care for Medicaid beneficiaries who have cancer is the low physician payment rates under the Medicaid program. Medicaid, on average, pays physicians 66 percent of what Medicare pays—and Medicare pay rates are below those of most private insurers, Polite said.


For that reason, some physicians limit the number of Medicaid patients they will accept. Indeed, a 2011 survey found that only 73 percent of specialty physicians were accepting new Medicaid patients at the time the survey was conducted. That limits patient access to specialty care.

“Many Medicaid patients will not be able to find a physician or resort to obtaining care in an emergency room,” Polite said. “This is especially problematic for patients with cancer because delay in treatment may have life-threatening consequences.”

 ASCO’s policy recommendations include:

·        Expand insurance coverage for individuals below the federal poverty level in all 50 states. Currently, 27 states and the District of Columbia are expanding coverage to patients below the poverty threshold, but 21 states are not doing so and two are continuing to debate the issue.

·        Ensure that oral medications for cancer treatment and supportive care have the same out-of-pocket cost limits for Medicaid patients as intravenous chemotherapy treatments. Currently, the 20% copays allowed for oral medications make them cost-prohibitive for many low-income patients.

·        Make sure that all Medicaid patients have coverage for the routine patient care costs associated with approved clinical trials.

·        Extend the ACA-provided mandates—cancer screening and diagnostic follow-up are available without copays to individuals covered under Medicaid expansion—to all Medicaid patients.

·        Require coverage for genetic testing, without copays, to individuals at high risk for inheritable cancer.

Thursday, November 06, 2014

CancerLinQ, the cancer care informatics system being developed by the American Society of Clinical Oncology, will take a leap forward in early  2015 when 15 oncology practices begin submitting patient data to the system.

Those so-called “vanguard” practices—including cancer centers, hospital systems and community practices— will take CancerLinQ for a test drive as ASCO prepares for a full-scale rollout in late 2015. The system will extract information—a patient’s entire medical record, including physician notes—from the practices’ electronic health record system to a data repository unlike anything that currently exists.

“It’s not a registry for predetermined questions,” said ASCO President Peter Yu, MD, who provided an update on the massive project at the Quality Care Symposium last month. “We’re free to explore whatever questions we wish to have. And we will have real-world data so we are not limited to clinical trials data, which, while very important and very granulator, often doesn’t represent the reality of our patients.”

CancerLinQ is expected to accelerate new knowledge about treatments and, thus, speed development of cancer care guidelines and clinical decision support systems.

What’s happening now:

·     Ten teams of technology companies responded this summer to ASCO’s request for proposals to develop CancerLinQ with the full functionality that its supporters envision. Altogether more than 50 companies, including major players like IBM and Accenture, were represented in the proposals. “No single company could do everything, but so they came together in groups,” Yu said.

·      ASCO expects to announce the winning proposal within the next several weeks.

·      ASCO’s Conquer Cancer Foundation is continuing to raise money to fund CancerLinQ development. As of July, $23.1 million had been pledged.

·      Six committees—business strategy, physician advisory, patient advisory, technology assessment, patient reported outcomes, and regulatory advisory—have been appointed to oversee CancerLinQ’s launch. Click here and scroll nearly to the bottom to see who is serving on those committees.


A CancerLinQ prototype using more than 170,000 de-identified breast cancer cases proved that the concept—patient data collected from many disparate electronic health record systems--can be analyzed to make useful observations, and will work.

Saturday, October 25, 2014


If the first day of the Palliative Care in Oncology Symposium had the exuberance of a toddler, the second day had the emotional roller-coaster of the teenage years.


Everyone in the Grand Ballroom started the day with a good laugh when palliative care expert Charles Von Gunten, MD, from OhioHealth, shared a satirical video that highlighted the never-say-die mentality of modern medicine.


But refusing to offer palliative care services that could alleviate suffering is not funny, and the room turned somber when Ira Byock, MD, now Chief Medical Officer for the Institute for Human Caring of Providence Health and Services and Professor of Medicine and Community & Family Medicine at the Geisel School of Medicine at

Dartmouth, expressed frustration that so many physicians refuse to give their patients access to palliative care services.


“We are doing brink-of-death care, not end-of-life care, let alone concurrent care,” he said. “It is time to call out bad care” when physicians are not being honest with their patients about their prognosis and letting them benefit from palliation.


A little later, a wave of tension lilted through the ballroom when Dorothy Keefe, MD, Clinical Director of the Royal Adelaide Hospital Cancer Centre in Australia, discussed the terms “supportive care” versus “palliative care.” While the term “palliative care” is used throughout the continuum in the U.S., she suggested that “supportive care”—which is used more prominently in some other countries—is a less frightening term that should be used for services provided to patients who are being treated for cure.


That idea did not sit well with one of her fellow panelists nor with the Twitter crowd, one of whom tweeted: “Pallcare should not get involved with patients whose care is curative." Really? #pallcare likes to help people live too.”


In the afternoon abstract session, a study about burnout among specialty palliative care clinicians generated the most interest—and it seemed to depress the entire audience.  Arif Kamal, MD, from Duke University Medical Center, presented results of a survey of members of the American Academy of Hospice and Palliative Medicine that showed palliative care physicians suffer higher levels of burnout than medical or radiation oncologists and other clinicians. In fact, 62 percent of respondents reported burnout; and more than half said they intend to leave the field within 10 years.


Next year’s conference is already scheduled: Oct. 9-10 at the Westin Copley Place in Boston.

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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.