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Practice Matters

News from Lola Butcher about health policy and practice management issues of importance to oncologists

Saturday, December 19, 2015

If you were choosing a medical school today, what would you look for?


The recent announcement that Kaiser Permanente, one of the country’s largest healthcare delivery and payment systems, plans to open the Kaiser Permanente School of Medicine in fall 2019 got me thinking about that.


Kaiser joins a raft of new medical schools trying to head off the predicted physician shortage. Three schools received preliminary accreditation earlier this year, giving the U.S. a record 144 medical schools. Together with established medical schools, they will try to address the broad dissatisfaction with graduate medical education in America.


The Institute of Medicine’s 2014 Graduate Medical Education That Meets the Nation's Health Needs report was summarized by Institute for Healthcare Improvement’s Don Goldmann this way:


“The IOM report correctly notes that the current system produces a physician workforce that is not sufficiently diverse, is over-weighted towards specialty rather than primary care, and is mal-distributed, creating shortages in rural and underserved communities. Medical residents spend a disproportionate amount of time on hospital wards rather than in primary care clinics or the community. Despite recent progress in some programs, residents generally leave training with inadequate competencies in interprofessional teamwork, coordination of care, cultural sensitivity, health economics and ‘right use’ of diagnostic tests and treatments, quality improvement, and (surprisingly) health information technology and mobile health (or mHealth).”


The folks at Kaiser Permanente must have read the report. The press release announcing their plans said the new school will “redesign physician education” by:

·    Providing high-quality care outside of traditional medical settings;

·    Acknowledging the importance of collaboration and teamwork to inform treatment decisions;

·    Addressing disparities in health;

·    Promoting cultural competency and understanding; and

·    Teaching advanced skills in decision-making, teamwork, the use of technology, evidenced-based medicine and communication tailored to specific populations.


“Opening a medical school and influencing physician education is based on our belief that the new models of care mean we must reimagine how physicians are trained,” Bernard Tyson, Chairman and CEO of Kaiser Foundation Health Plan and Kaiser Foundation Hospitals, said in the release.

Tuesday, November 24, 2015

Many payment reform ideas are quite complicated, so the one-payment-per-year pilot that the University of Texas MD Anderson Cancer Center and UnitedHealthcare announced last year seemed extremely simple by comparison.


It turns out, though, that simple does not necessarily mean easy. When I tracked down Dr. Thomas Feeley, an anesthesiologist who is head of MD Anderson’s Institute for Cancer Care Innovation, to get a status report, he said payment reform is rough-sledding even for a highly sophisticated provider organization and one of the nation’s largest private payers.


Feeley, a senior fellow at the Institute for Strategy and Competitiveness at Harvard Business School and Professor in the Department of Health Services Research at MD Anderson, said the pilot with UnitedHealthcare—about 40 patients have been enrolled to date—is all the payment experimentation the organization can handle at the moment. There are no plans to expand the pilot to additional tumor types or try out other payment innovations, he said, noting that MD Anderson’s job is to figure out whether its bundling idea is going to work.


Feeley encourages oncology practices to be proactive in experimenting with new payment methods. That said, he thinks a new payment system for cancer care will evolve over a long period of time as providers and payers grapple with what they are trying to accomplish.


“We think the term ‘value-based payment’ is a little bit ambiguous,” he said. “It depends upon how you define value.”


In our conversation, Feeley compared MD Anderson’s pilot with another bold idea, the Oncology Care Model being planned by the Centers for Medicare & Medicaid Services.


Last year UnitedHealthcare and MD Anderson announced a pilot for a new way of paying for cancer care. Remind us how that payment system works.

Tom Feeley:  “Our agreement with United Healthcare is that any newly diagnosed patients with head and neck cancer, including all cancers of the oral cavity, larynx, lip, and carotid gland, would be eligible for this pilot as long as they were newly diagnosed and had not previously had any treatment.


“The patients are evaluated by our multidisciplinary cancer care team, and once the patients have had a course of treatment agreed upon in our multidisciplinary planning conference, we then enter the patient into one of four bundled payment schemes—basically four different payment amounts, depending upon the treatments that the clinicians plan for those patients.


“We also have a modifier for each of those four bundles in the event that a patient has two or more comorbidity factors. That adds an incremental amount to the payment. The payments are prospective--that is, as soon as we agree that the patient is in one of those bundles, we send a claim to UnitedHealthcare and they pay us for everything that we do at MD Anderson. That includes all surgery, all chemotherapy, all radiation oncology, any plastic surgery treatment that’s necessary, any consultations with cardiology or pulmonary--any services that are provided by MD Anderson with the exception of proton therapy and dental restorations. It does include speech therapy, hospitalizations, emergency center visits, and almost anything you could imagine that a patient with cancer would need.


“The period of the coverage is for one year. We track certain patient outcomes, but that is at this point only pay-for-reporting, not pay-for-performance.”


We hear a lot about the concept of value in cancer care these days. Does this payment system increase the value of care? 

“We’re trying to assess that. One of the interesting things about episode-based payment for cancer care is that a lot of people think it will increase the value of cancer care by controlling costs and improving outcomes--yet there’s never been any real careful evaluations of this type of payment for multispecialty care like we provide at MD Anderson.


“There is some evidence in a pilot that UnitedHealthcare did with medical oncologists that demonstrated cost reductions in a medical oncology practice. But we’re really trying to evaluate (a more comprehensive approach to bundling) to see if we can improve our outcomes and control the cost of care delivery.”


You have several months experience with this payment system now. How is it going? And what have you learned so far?

“We’ve enrolled over 40 patients to date. I think the biggest learning has been that, because this is not paid in the fee-for-service system, both our billing and UnitedHealthcare’s claims processing aren’t prepared for many of these new reimbursement models.


“What we found is that we have to be very, very careful how we identify patients and make sure they qualify for the bundle. We have to then determine what bundle they actually qualify for. And then, all of the claims management on our side and on the payer’s side are all manual.


“That has slowed down the claims process. Even though we are only processing one claim rather than multiple claims, it slowed down the time that these claims have taken to get paid. That’s not an insurmountable issue.


“Over time, as both provider organizations and payers get more used to these type of systems, they will develop ways of working around the manual processes and automating the processes for doing this sort of payment. But it was a little bit of a surprise to us that it was somewhat labor-intensive. Intuitively, one would think you send one bill and get one check so it should be much easier. But it actually isn’t.”


On the care delivery side, any lessons learned?

I think it’s too early: Number one, our clinicians in head and neck cancer are a fabulous group of clinicians, physicians, nurses. Everybody in the care team is absolutely dedicated to making care the most efficient and most optimal for every patient. Early on, our clinicians asked that they not know who is in the bundle and who isn’t, so that they could aim to provide the same high-quality care to all of our patients, whether they were being paid in fee-for-service or in a bundled pricing methodology.


“Our clinicians have worked very hard to really streamline their processes so that they are not wasting services. They’re doing what patients need, when they need it, and not holding back on any services that patients need. Not knowing whether a patient is in a bundle or not sort of eliminates any possibility of people holding back any services because of a fixed payment.”


Is MD Anderson experimenting with any other new payment methods? If yes, what are you learning from them?

“Actually, no. This is enough at this point in time. First of all, this is a major change for an organization that has a very well-organized way of processing claims. I think if we introduced multiple other reimbursement methodologies, we would overburden the system.


“We are thinking about, but not really planning, whether there would be other diseases that we could test bundling in. But first we are trying to see how well we perform, from both a performance and a clinical outcome perspective. We are too early into the pilot to be able to make any judgments. We are going to do this one step at a time.


Your bundled payment system is very different from the Oncology Care Model that the Centers for Medicare & Medicaid Services is planning to launch. Do you see the system you are piloting with UnitedHealthcare to be complementary to what CMS is thinking--or contradictory?

“It is certainly not contradictory. CMS is working with one set of providers for cancer care—it’s important to remember that cancer care is delivered by medical oncologists, surgical oncologists, radiation oncologists. The CMS Oncology Care Model is really focused on those medical oncologists who are treating cancer patients with chemotherapy alone. So the OCM differs from our model in that we are bundling all modalities of care.


“The other major difference is that the Oncology Care Model still uses Medicare fee-for-service to pay for things, except they add on two things that they sort of equate with turning into a bundle. They add in a fee of $160 per beneficiary per month for coordinating care. And they also add in a payment for performance based on some quality measures.


“Also, CMS is planning a six-month bundle as opposed to a one-year bundle. And ours is a prospective payment. We get our payment upfront, and we hopefully spend our money wisely. Medicare’s payment is a retrospective payment; providers are paid fee-for-service, and then these other things are done towards the end.


“Both models need to be tested. I think the important thing about reimbursement reform is that every provider organization needs to be testing what they think will work, and every payer needs to be evaluating how they can move into a value-based payment system.”


Based on your experience to date, what should oncologists and practice managers know about payment reform for oncology in the years ahead?

“I would say the first thing is they should be prepared to change. They should be prepared to test some of these new models that are being proposed by payers. And they should be thinking about proposing their models to payers, as well.


“We know that change is likely coming. We just don’t know what form it will take. We think the term ‘value-based payment’ is a little bit ambiguous. It depends upon how you define value.


“Oncology practice managers need to understand that the landscape is changing, but I don’t believe it’s going to change overnight. I think this is going to be an evolutionary change as both provider organizations and payers work out how to pay for value. This is going to be a gradual journey.


“I think people need to pay attention to these pilots and see how they go. What works in one environment might not work in another. For MD Anderson, for example, a bundled pricing system where the doctors, the hospital, and the clinics are paid by one check, and then payments are distributed internally, works well because all the physicians are on salary. We are accustomed to fee-for-service for payments to the the institution, but not as a way of paying individuals. In the private practice setting, there will be decisions that have to be made about how to distribute lump sum payments when they arrive. Those will become difficult conversations to have.


“I would point out that in orthopedic surgery, where CMS is piloting a bundled payment system for joint replacements, that’s being made mandatory in certain geographic areas around the U.S. And people are having to figure out how the person who gets the bundled payment will distribute the revenue that they get to the other providers in their organization, or in related organizations that are caring for those patients.


“So I think it is well worth practice managers observing what’s happening in other test environments for new reimbursement models, and not simply waiting for what’s going to happen in oncology. A lot of the learning about how these things will play out is already developing in other specialties that have much greater experience with bundled pricing and other pay-for-performance type initiatives.”


Listen to a podcast of the conversation in OT's Nov. 25 iPad issue.

Thursday, November 19, 2015

First, let’s take a deep breath to remember why the Sustainable Growth Rate formula for physician pay was so bad and why it is very good that it is being replaced.


Now brace yourself, because getting to a new payment system for physicians is not going to be easy. Here’s a great overview about the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and here’s a shorter version of the same information.


Get comfortable with these words: MIPS and APMs, the two new options that physicians will be paid through in the future. The first acronym is for Merit-Based Incentive Payment System, and the second is for Alternative Payment Models. They are very different systems (see aforementioned great overview), but both will reward/punish oncologists based on their performance. 


Beyond that, details have not been determined. The comment period for oncologists and others to tell the Centers for Medicare and Medicaid Services (CMS) what to do just ended this week, so the agency will be sifting through all that information and let us know what it comes up with. Don’t worry—I’ll keep you posted.


One organization that weighed in with ideas is the American Society of Clinical Oncology, which sent CMS a list of 11 principles to use as it develops the MIPS and APMs.


"MACRA is an important opportunity for CMS and ASCO to work together to create a fair and sustainable reimbursement system for clinical oncology that serves the best interests of Medicare beneficiaries and the Medicare program," ASCO President Julie M. Vose, MD, said in the letter to CMS.


Those principles include:

·     Ensuring that there are multiple APMs focused on clinical oncology to permit oncologists to select a model that works for them;

·    Creating multiple ways to facilitate transitions for physicians who initially participate in MIPS to subsequently move to an APM;   

·    Improving quality reporting through the use of data registries such as ASCO’s Quality Oncology Practice Initiative;

·    Facilitating group reporting of quality data in APMs and MIPS;

·    Partnering with ASCO to create a risk adjustment methodology that is specific to cancer treatment; and

·    Ensuring that MIPS and APMs do not hinder access to clinical trials. 

Monday, November 9, 2015

Some advanced cancer patients will not have to choose between curative therapy and hospice care after the Centers for Medicare & Medicaid Services (CMS) launches the Medicare Care Choices Model on Jan. 1.

Care Choices is a five-year program in which CMS will explore whether certain Medicare patients with terminal illnesses would be well served by the opportunity to receive hospice services while they are also receiving chemotherapy or other treatment.


Leanne Burrack, RN, Executive Director of Hospice for UnityPoint at Home in three Midwestern states, said she believes the program will make it easier for patients to accept the hospice services that could make their lives easier as their disease progresses.


“They don’t have to let go of one rope to grab onto another rope,” she said. “They can hold onto both ropes until they are comfortable.”


Similarly, Diane Meier, MD, Director of the Center to Advance Palliative Care, said she hopes the Care Choices Model will contribute to a cultural change that makes concurrent palliative care the standard of care for people with serious illnesses.


“It will hopefully demonstrate to oncologists that they can continue their specialty-level care for their patients in partnership with a team that will focus on things that are outside the oncologist’s bailiwick—like family caregiver exhaustion, social issues, family conflict, and intractable constipation. These are things that oncologists have neither the training nor the time to address, yet I think every oncologist would agree that these are incredibly important issues in terms of optimizing their patients’ health and wellbeing.”


Multiple Choices for Patients

The Care Choices program is not identified as a pilot or a demonstration, but rather a five-year program that will allow Medicare to evaluate whether eligible patients will embrace the chance to receive hospice services.


The program seeks to address the fact that only 47 percent of Medicare patients and 42 percent of dual eligibles (patients eligible for both Medicare and Medicaid) who qualify for hospice services actually enroll—and most of those for only a short period of time very near the end of life. The government believes that this is because, under the current rules for hospice, patients must choose between the palliative services available via hospice and potentially curative therapy.


Care Choices targets patients who live at home and who are struggling, as evidenced by the requirement that they have had at least two hospitalizations related to their terminal illness in the previous year.


Under this program, physician services, medications, medical equipment, short-term inpatient care for pain or symptom management, and some services, such as physical or occupational therapy, will be paid for through the traditional Medicare fee-for-service system. Participating hospices will receive a per-beneficiary, per-month fee for nursing, social work, bath aide/homemaker services, chaplain, and respite care services.


Intense Interest

Although the monthly fee is small—$200 a month for patients enrolled in the program less than 15 days; $400 a month for those enrolled 15 days or longer—hospice providers went wild for the idea when it was first announced.


CMS originally planned to accept 30 hospices and enroll up to 30,000 patients over a three-year period. But because of the intense interest, the program was expanded to include more than 140 hospice programs serving up to 150,000 patients over five years.


About half will start on Jan. 1, 2016, and the rest will begin Jan. 1, 2018. 


Longer Periods of Hospice Care

“The reason we are so excited to be part of this program is because our referrals to hospice are coming so late,” Burrack said. “That means we are only able to support that patient and family for a very short length of time.”


UnityPoint Health, a large health system serving Iowa, Illinois, and Wisconsin, provides inpatient palliative care and hospice services in all its markets. Three UnityPoint Hospice locations were chosen to participate in the Medicare Care Choices program; the Fort Dodge, Iowa, location will begin Jan. 1, while the other two will join in Phase 2, in 2018.


Burrack noted that the median length of stay at UnityPoint’s hospice-at-home programs currently ranges from three to 11 days—much shorter than the national median of 21 days. Similarly, the average length of stay at UnityPoint hospices is 45 to 50 days, compared with a national average of more than 75 days.


When patients enroll in hospice just a few days before death, the experience is likely to be less than optimal for all parties. Patients and their family caregivers must deal with the intake process, receipt of hospice equipment and supplies, and other logistics but they receive the support that hospice offers for only a very brief period.


“Not only do the patients and families not benefit from those services over an extended amount of time, but the staff caring for the patient and family members are put in a very complex and possibly crisis-management type situation,” said Monique Reese, DNP, Chief Clinical Officer of UnityPoint Clinic and UnityPoint at Home.


Better Informed

Patients who receive concurrent care through the Care Choices program will be able to experience the benefits of hospice support. And when it is appropriate for them to consider discontinuing curative therapy and moving to the traditional hospice benefit, they are likely to be better informed about the services they can expect.


“We want to help them understand that electing the hospice benefit does not mean they are actively dying,” Burrack said. “We really do focus on living and how we can support them to live their best life while the disease is progressing.”


That means keeping patients out of the hospital, if possible. Patients become eligible for the Care Choices program only if they have two hospitalizations in a year, which suggests they are struggling with symptoms related to their diagnosis or the side effects of treatments. Chad Tuttle, President of Spectrum Health Continuing Care, said he believes that offering hospice services to patients undergoing treatment will prove to Medicare that concurrent care improves patients’ well-being while keeping them out of an inpatient bed.


“Our hope is that if this program is successful, Medicare will look at the results and say, ‘This is the strategy that should be brought in earlier, even before that second acute hospitalization,’” he said.


Improving Clinicians’ Comfort Level

One reason for the low hospice use among patients who qualify for the services is that physicians do not refer them until shortly before death. In a study that focused on palliative care, rather than hospice specifically, Yael Schenker, MD, MAS, a palliative care specialist at the University of Pittsburgh Cancer Institute (UPCI) in Pennsylvania and her colleagues shed some light as to why (OT 2/25/14 issue).


The research team interviewed 74 oncologists at UPCI, the University of California San Francisco Helen Diller Comprehensive Cancer Center, and Mount Sinai Tisch Cancer Institute, all three of which have comprehensive palliative care clinics. While some survey respondents did consider palliative care to be complementary to therapy, the results did uncover three physician barriers to referrals: a belief that palliative care is an alternative to and incompatible with cancer therapy; a belief that providing palliative care is the oncologist’s responsibility; and lack of awareness about palliative care services.


A significant minority of oncologists in that study (22 of 74) viewed palliative care as an alternative to cancer therapy. Writing in the Journal of Oncology Practice (2014;10: e37-e44), Schenker and her coauthors quoted one oncologist who said “If a patient is a chemotherapy candidate, they’re not a palliative care candidate.”


Engaging Physicians

Lisa VanderWel, Senior Administrator at Spectrum Health Hospice, said engaging physicians is a key component of her plan for participating in the Medicare Care Choices program. Spectrum Health Hospice, part of the Spectrum Health system, is one of 10 hospices in Michigan chosen to participate in the program.


“We are definitely going to go in front of our physician groups to educate them on this program,” she said. “We want the physicians to know what they can expect us to do for their patients at home. Communication and partnership are what’s really going to give patients the support they need.”


‘Not a Tipping Point’

Meier said she sees the Care Choices program as a good idea for increasing patients’ access to palliative care and hospice services, but not one that will bring about a tipping point.


“It’s just one lever among many that need to be applied, but by itself, it will certainly not be enough,” she said. “What we are seeing is a need for a culture change, not only in oncology but also in many specialties that care for people with serious complex illnesses.”


New Value-Based Payment Incentives

Meier advocates for new value-based payment incentives that encourage health care providers to engage patients in discussions about what to expect in the future and what matters most to them if their illness progresses; greater support for patients in their homes; and changes in medical education.


“The training of clinicians has been totally focused on the latest disease treatment,” she said. “It really has not included--and does not include even today--helping specialists such as oncologists to understand that there’s a lot more to the role of being a patient’s doctor than administering chemo or radiation or recommending surgery.”


Until now, Medicare’s payment policy has forced patients to choose either hospice care without access to their cancer physician or curative therapy without access to hospice services. Severing the patient/physician relationship when the patient is very ill does not feel right to either the patient or the physician.


“I’ve had many patients say, ‘I don’t understand why my oncologist is not in touch with me.’ And the oncologist says to me, ‘I can’t do anything for them; they’re on hospice,” Meier said. “And that’s sort of tragic because it trivializes the doctor-patient relationship to one of administering chemotherapy.”


VanderWel, at Spectrum Health Hospice, said she expects that physicians will embrace Medicare Care Choices when it becomes available: “I’m hopeful that they’re going to find this as quite a relief because they can continue with their treatment plan for their patients and we can provide patients the care that they need at home.”





The Medicare Care Choices Model is available for patients who:

          Have been enrolled in traditional Medicare for at least two years--patients who participate in Medicare Advantage or other managed care plan are not eligible;

          Have a diagnosis for terminal cancer, chronic obstructive pulmonary disease, congestive heart failure, or HIV/AIDS and meet the hospice definition of terminal illness;

          Have had at least two hospitalizations in the past year related to the qualifying diagnosis;

          Are expected to live six months or less;

          Live in a traditional home;

          Have not received hospice benefits in the past month; and

          Live in an area served by a hospice participating in the new program.


Monday, October 26, 2015

Most people agree that paying more for health care services provided in one setting than another is not a good idea. But a move to “site neutrality”—paying the same for services provided at a hospital outpatient department as at a physician’s office—may make the cure worse than the problem being solved, according to the American Society of Clinical Oncology.


That fear is what prompted ASCO to issue a policy statement on site-neutral payments in oncology as a special article in the Journal of Clinical Oncology.


Outpatient oncology services provided in a physician’s office are paid for under the Medicare Physician Fee Schedule (MPFS) while those provided in a hospital-owned outpatient department are paid for through the Hospital Outpatient Prospective Payment System (HOPPS). The two pay systems are totally different from one another, resulting in completely different payments for identical services.


Various proposals, including separate proposals issued by the Centers for Medicare &  Medicaid Services (CMS) and the Medicare Payment Advisory Committee (MedPAC), have been swirling for a while, and some observers are getting nervous.


CMS says that, in general, hospitals should be paid more because they have to provide around-the-clock care and emergency services, both of which are costly services that physician offices do not provide. CMS’s idea of site neutrality: limit physician fees for about 200 procedure billing codes where physician practices are paid more than hospital outpatient departments.


MedPAC, on the other hand, believes that Medicare should pay for services where patients can get access at the lowest cost, which means limiting the pay rate to hospital-owned facilities.


ASCO’s position is that the pay systems for hospitals and physician offices are both outdated, and choosing one over the other in the name of site-neutrality is a bad idea. Yes, Medicare would save money by adopting the physician-office pay rate for hospital outpatient departments; but Medicare is not adequately paying physician practices for many services they provide, so that move would do nothing to create a sustainable cancer care system.


Rather, ASCO wants to see comprehensive payment reform that makes the issue of site-neutrality go away on its own.


“As a number of initiatives in the private sector (see here and here) have demonstrated, the financial savings that can be achieved by transforming the oncology-delivery model are significant, perhaps dwarfing any savings derived from traditional site-neutrality initiatives,” the policy statement said.


ASCO’s recommendation: Adopt a new payment system that ensures adequate payment, regardless of the setting of care, to support the full scope of services needed to provide good care.


The organization stopped short of touting its Patient-Centered Oncology Payment as the only solution, but suggested that it is worth a look: “Policymakers should transform Medicare coding and payment for outpatient cancer care by implementing policies that are consistent with proposals such as the ASCO patient-centered oncology payment program and the CMS design of an oncology-focused model of care.”