Independent community oncology practices are critical to the fabric of cancer care in the United States. They allow patients nationwide to receive high-quality, affordable, and accessible care in the communities where they live and work.

 While the coronavirus disease 2019 (COVID-19) pandemic is highlighting how a community practice is the best source for patients to receive care close to home, it is also presenting several challenges for practices and their patients.

Patients—either nervous to access care or facing increased barriers— canceled appointments and delayed screening visits.

 On average, oncologists saw a 40% drop in weekly visits from new patients, and cancellations doubled during the first few months of the pandemic’s stay-at-home orders.

Lower patient volumes not only prevented oncologists and other specialists throughout the country from being able to fully support their communities but also created new financial constraints for these providers. According to 1 survey, 50% of private practices had to furlough office staff, and almost 25% were forced to make permanent layoffs.

 As a result, practices needed to find new ways to provide the care their community needed and to maintain revenues, allowing them to remain viable.

Some practices already had a business strategy in place that positioned them for success. For example, Gabrail Cancer Center in Canton, Ohio, is thriving amid the pandemic because of the trust and partnerships it has built over the years to meet the needs of a rural town that is home to several food processing plants and an Amish community. Gabrail’s ability to look broadly at regional needs of local patients, businesses, and the community at large provides a model from which many practices can learn.

The History: Embedding a Practice Into the Community

When Nashat Gabrail, MD, founded Gabrail Cancer Center in 1990, he immediately recognized the importance of building connections with other local businesses and meeting potential patients where they already were. Knowing his Canton, Ohio, community is primarily an industrial and agricultural area with many food processing plants and home to a large Amish community, he saw an opportunity to help meet the health care needs of residents and to create a thriving oncology practice with multiple revenue streams.

He approached the large local food manufacturers and, over time, worked with them to establish on-site clinics at their facilities that provided both preventive and acute care, and also offered oncology screenings and consultations. The practice has maintained some of these clinics for close to a decade, and as COVID-19 began to spread— impacting manufacturing plants (which are densely populated) at greater rates than other businesses—Gabrail was well positioned to provide support.

Early on in the practice’s history, Gabrail’s team built relationships within the local Amish community and worked to gain their trust by offering many of them a nearby, affordable option for cancer care.

In addition, Gabrail Cancer Center implemented a clinical trials program to give local patients convenient access to the most innovative therapies without having to venture hours away to cancer research sites or large hospitals.

The Opportunity: Falling Cancer Screenings but Growing Health Care Needs

Many oncology practices across the country saw new patient referrals fall at the start of the pandemic as screening appointments dropped weekly, according to 1 survey.

 Clinical trial programs were also shutting down. According to a recent American Cancer Society survey, more than 50% of cancer researchers reported that their work was temporarily put on hold due to the pandemic.

At the same time, food manufacturing facilities across the country were finding themselves at particular risk for COVID19 outbreaks due to the density of their workforce. Counties with food processing plants were experiencing infection rates higher than 75% of other US counties.

 These outbreaks were threatening the health of the workers and their families, and they were causing facilities to shut down, leading to food shortages throughout the United States.

To compound these issues, Amish populations across Ohio experienced spikes in COVID-19 cases.

 These outbreaks affected the Amish community in Stark County, Ohio, and in surrounding counties with limited access to local care.

Gabrail saw an opportunity to help address these issues and to protect the longterm viability of his practice: He needed to evolve, invest, and expand.

The Approach: Tailoring Services Based on Need; Ensuring Success

Gabrail leveraged his practice’s existing local partnerships to expand his services, based on the specific needs of managing the spread of COVID-19 as well as its indirect consequences. Gabrail began working with local manufacturers to screen employees according to the Centers for Disease Control and Prevention COVID-19 guidelines.

Gabrail and his team offered temperature checks to employees before they entered the food plant, at their lunchtime, and again when their shift was complete. Should an employee show any symptoms of illness, they were moved to an off-site, outdoor clinic for flu and coronavirus testing.

Gabrail even created a hotline for the food plant employees that they could call to be assessed before reporting to work. And nurses helped patients complete online questionnaires to determine illness or mental health issues that could be exacerbated by the pandemic. These added measures helped ensure the staff was at low risk for infection yet still maintained their essential duties— avoiding supply-chain disruption.

Ultimately, Gabrail avoided practice constriction and, instead, expanded his staff to provide health assessments for more than 2200 employees in the Canton area—which often included 3 assessments per employee, per shift. Recently, Gabrail Cancer Center also expanded its offerings to other states to do mass testing and provide services for more food plants.

Gabrail also had the opportunity to strengthen his relationships with the local Amish community when it experienced a COVID-19 outbreak. When local Amish learned that Gabrail has established clinics at local companies, they, too, turned to his practice. Gabrail Cancer Center would assess their symptoms remotely and if 

required, would send staff to do viral testing and treat them.

Gabrail also expanded existing services to help members of the Amish community continue to get access to necessary cancer care without fear of contraction. For instance, his cancer center delivered prescription drugs to Amish homes for convenience and to minimize COVID-19 exposure. For current patients, Gabrail purchased a 16-seat van to transport Amish patients receiving chemotherapy and other infusions to ensure they could safely continue treatment.

Also important to both the Amish and larger community was Gabrail Cancer Center’s commitment to maintaining its access to clinical trials. The center kept its program open and added new clinical trials to make up for the research sites that had to close amid the pandemic. As a result, it became the alternative referral site for practice and academic centers.

The Outcome: Increasing Patient Volume; Protecting a Viable Business

By July 2020, Gabrail Cancer Center was supporting 8 food processing plants on a 24/7 basis. Since partnering with Gabrail, all the plants that implemented his screening and health care support have avoided shutdowns and stayed open.

While many US practices were suffering from decreased patient volume, Gabrail Cancer Center reported an uptick in new patients seeking clinical trials. And with this ongoing demand for care and services from local communities and businesses, Gabrail hired more than 43 highly qualified providers who had been furloughed or laid off from other local hospitals.

Gabrail also leveraged the surge in need and temporary revenue to help ensure his practice will remain viable. He was even able to complete the construction of a new building with a drive-through for his retail pharmacy in July. Previously, the pharmacy had been located in a small space inside the cancer center.

And, potentially most important for the future, Gabrail further positioned himself within the community as a connected, embedded provider who understands the unique needs of the region.

The Takeaway: Learning From the Model and Looking Ahead

Not every practice will be able to do what Gabrail Cancer Center did, but the broader implications of its approach offer learnings for all community oncologists. Gabrail’s ability to understand and assess the region’s most critical needs and think creatively about how its services could fill those gaps— even temporarily—is an important lesson. All community-based care providers have the opportunity to use their position and local knowledge to adapt to whatever threatens their community’s health.

“Community providers should always be considering other revenue streams for their practice,” Gabrail said. “This pandemic represented an unexpected challenge for us, and we are providing a service to our community and the businesses, helping to keep our own community healthier.”

As practices have begun to return to more “normal” day-to-day operations in the face of growing numbers of COVID-19 infections, patients may continue resisting care. They may think they are protecting their health by staying home and avoiding centralized points of care, like community practices. But thousands of excess cancer deaths are expected to occur over the next decade as a result of missed screenings, delays in diagnosis, and reductions in oncology care caused by the COVID-19 pandemic.

It’s imperative that oncology practices proactively engage their patients and address their fears. Through social channels and their marketing efforts, oncology practices can reinforce that now is the time for patients to prioritize their health. Oncology practices can also connect with and demonstrate a commitment to their patients through surveys and follow-up phone calls.

Community-based care providers also need to share all new protocols and procedures they are implementing to ensure patients can be safely seen and treated.

Fact sheet: what is community oncology? Community Oncology Alliance. 2017. Accessed August 6, 2020. https://bit.ly/3a2IF38

Yermal B. Amid pandemic, public wary of seeking non-coronavirus care from providers. Morning Consult. May 7, 2020. Accessed August 6, 2020. https://bit.ly/31tKbaN

Lash Group. Patient Assistance in the Wake of COVID19. Webinar. Xcenda. May 8, 2020. Accessed August 6, 2020. https://bit.ly/3kiCZGN

The early impact of COVID-19 on community practices. Roundtable. AmerisourceBergen. July 28, 2020. Accessed August 6, 2020. https://bit.ly/2DkU8iK

Survey: half of cancer researchers report their work is on hold. News release. American Cancer Society. May 8, 2020. Accessed August 6, 2020. https://bit.ly/2EXWq7O

Bagenstose K, Chadde S, Wynn M. Coronavirus at meatpacking plants worse than first thought, USA Today investigation finds. USA Today. April 22, 2020. Accessed August 6, 2020. https://bit.ly/3fAlpL4

Thompson A. Coronavirus: Ohio’s Amish Country sees cases spike as tourists return. Wooster Daily Record. June 16, 2020. Accessed August 6, 2020. https://bit.ly/3a8823x

Sharpless NE. COVID-19 and cancer. Science. 2020;368(6497):1290. doi:10.1126/science.abd3377

Articles

The coronavirus disease 2019 pandemic is highlighting how independent community oncology practices are the best source for patients to receive care close to home, while also presenting several challenges for practices and their patients.

Community Practice Provides Model   for Finding New Revenue in COVID-19 Era

Today, 35% of oncology drugs in the pipeline are oral, according to a recent report by the Community Oncology Alliance (COA). With the rise of oral oncolytic prescribing and development, more oncology practices are implementing in-office dispensing programs to provide a seamless treatment experience for patients. The terminology for this practice is now commonly referred to as medically integrated dispensing, which more accurately reflects the level of clinically coordinated care that patients can expect from their community physicians.

Medically integrated dispensing programs have emerged as crucial assets for community oncology practices as they work to stay viable in an ultracompetitive market. The value proposition is relatively simple: Community practices that are dispensing are capturing additional revenue from filling prescriptions and staying more connected to their patients. The patient connection is key. Personalized care has always differentiated community oncology practices, and that level of care is amplified when prescription matters are closely tracked in the patient’s medical record.

Although practices participating in the Oncology Care Model (OCM) are held accountable for the quality of patient care they provide, the Merit- Based Incentive Payment System also is changing the value equation for all practices by requiring new reporting and measurement standards. These dynamics increase the importance of how well a practice coordinates care with its patients, which is harder when prescriptions are filled outside the practice. In such cases, extra coordination and communication are needed to ensure that the care team supports the patients appropriately. When coordination and communication break down, physicians often lose track of refills and other therapy concerns. A medically integrated dispensing program can improve patient adherence and the management of adverse events. Having this is critical to avoid penalties for unnecessary patient hospitalizations.

While medically integrated dispensing has many benefits for community practices, challenges do exist.

Keeping prescriptions within the practice can be an uphill battle. Pharmacy benefit manager (PBM) formularies and preferred network frameworks often prohibit or limit dispensing by oncology practices. This can interfere with the start of therapy and its continuity. An oncology practice’s familiarity with patient medical histories and preauthorization needs can help accelerate access to medication.

Direct and indirect remuneration (DIR) fees are what a dispenser pays to a Medicare Part D sponsor or its PBM, and these can add up to an impediment to the success of an in-office dispensing program. DIR fees were initially established to account for all costs associated with prescription medications, including manufacturer rebates and other price concessions. Today, however, DIR fees can include “clawback” fees, which are assessed well after the point of sale and can hit a community practice’s bottom line hard. This constitutes another hurdle for community practices trying to establish in-office dispensing programs. With current DIR fees, oncologists may not know if they’ll be fairly paid for the therapies they dispense. Such financial risk can hold practices back from developing medically integrated dispensing programs. Much work still needs to be done, particularly on Capitol Hill, in communicating how these fees ultimately affect the patients.

Oncologists should consider evaluating a variety of partners, from technology companies and consultants to group purchasing organizations, to determine who can connect them with the resources they need for successful in-practice dispensing. With advanced analytics that leverage electronic medical records and patient portal data, community oncologists will have the information they need to gauge practice performance and optimize patient care. These data can be packaged to show manufacturers and payers the benefit of including dispensing practices as a channel for product access.

Oncologists also need to pay close attention to insights and learnings derived from the early pilot phases of value-based care models, such as the OCM and Community Oncology Medical Home program. It can take significant resources to build an infrastructure capable of supporting in-office dispensing. Oncologists should leverage their practice’s prescribing patterns to justify the use of these resources and establish an efficient and effective program. With a firm grasp and holistic view of these compiled data, community oncologists will be equipped to present a strong case for how in-practice dispensing lowers the costs of cancer care.

Physicians should also leverage best practices to position their community practices for success. An example of this is hiring and optimizing the role of the pharmacy technician, a critical position in a medically integrated dispensing program. A technician’s daily responsibilities include managing preauthorizations and refills, connecting patients who cannot afford specific medications with financial assistance programs, tracking what the practice can and cannot dispense, and providing back-end monitoring of the inventory management system and dispensing plan. The foundational support these technicians provide helps practices increase the speed to therapy for patients.

To ensure progress is made on the opportunities presented by in-practice dispensing, many oncologists have taken their cause to Washington. Organizations like COA’s Community Oncology Pharmacy Association (COPA) and Patient Advocacy Network (CPAN) have been especially active on this front. In 2016, COPA cancer care advocates partnered with the Accreditation Commission for Health Care to develop a specialty pharmacy accreditation that was tailored to physicians’ offices with an oncology distinction. This was a significant turning point for community practices.

As the oncology landscape evolves, there is more action being taken by these community oncology advocates, especially with respect to lowering DIR fees. For example, back in April, there were 100 CPAN cancer care advocates on Capitol Hill urging Congress to demand more transparency and accountability from PBMs on medication management and DIR fees. As COPA and COA continue to grow, oncologists will have more influence on Capitol Hill and more opportunities to have their voices heard and needs met.

Medically integrated dispensing keeps prescriptions close to the prescriber. By controlling this process, there is potential for optimized outcomes and lower healthcare costs, 2 necessities in today’s value-based payment environment. However, hurdles exist for oncologists to capitalize on this opportunity. With access to the right data-driven resources and business insights, community oncologists can continue to implement efficient and effective dispensing programs into their practices and communicate the value of these programs back to payers, manufacturers, and, ultimately, patients. Getting involved in advocacy efforts that push legislators to reevaluate DIR fees will help make in-office dispensing a realistic opportunity for more practices.

With the rise of oral oncolytic prescribing and development, more oncology practices are implementing in-office dispensing programs to provide a seamless treatment experience for patients.

Making the Case for Medically Integrated Dispensing

Independent community oncologists play a vital role in cancer treatment for hundreds of thousands of Americans. In fact, nearly 55% of patients with cancer in the United States receive treatment in the community setting.

 Community practices provide patients with access to local, good-quality treatment that allows them to stay close to family, friends, and other forms of support. Also, it is widely acknowledged that community oncology is the lowest-cost setting for care, especially when it comes to travel expenses and other common barriers to care. With questions regarding Medicare Part B and the recent update to the tax code up in the air, 2018 is turning out to be a year of uncertainty for community providers. Now is a critical time for oncologists to engage with these issues by advocating for themselves and their peers while also becoming more efficient, transparent, and accountable in order to realize greater opportunities in the future.

Like all other industries, healthcare does not exist in a bubble. Outside forces from a variety of stakeholders affect providers of all kinds. Regulatory pressures and shifting laws and guidelines can pose a threat to the viability of community practices, because many regulations limit payment for treatments and services. Community oncologists operate on razor-thin margins, which makes the slightest policy or regulatory change potentially catastrophic to their bottom line and overall viability. This is especially true when it comes to Medicare Part B. Any additional regulation that lowers payment under Part B could render it impossible for community oncologists to continue to operate effectively and efficiently.

Over the past several years, independent oncology practices across the country have built innovative and sound infrastructures to deliver increasingly complex chemotherapy regimens. From establishing infusion centers to in-office dispensing of oral oncolytics, community practices are now commonly responsible for managing and maintaining inventory of specialty products to treat their patients. To sustain this level of treatment, practices buy product at risk, with the understanding and hope that they’ll be properly paid at the average sales price (ASP) plus 6% down the line. However, regulators continue to limit payment.

Under the Budget Control Act of 2011, automatic sequester cuts, including a 2% per year reduction in Medicare spending, were established to keep federal spending in balance with rising national debt. This lowered payment for a drug to ASP plus 4%, cutting community oncologists’ operational income by nearly 30%. Any further regulation limiting Part B payment would make the infusion and dispensing systems community practices have built untenable. There’s already significant pressure for oncologists to be more aggressive about collecting payments from Medicare, other payers, and patients, and this additional change could push community oncologists to a place where they are no longer able to maintain in-office inventories of chemotherapy treatments.

On December 22, 2017, President Donald Trump signed the Tax Cuts and Jobs Act of 2017 into law. This reduced taxes for individuals and businesses and repealed the individual mandate included in the Affordable Care Act. Additional Medicare sequester cuts are expected, because the policy is projected to add $1.5 trillion to the federal deficit over the next 10 years. In addition, the recent tax bill included the Pay-As-You-Go Act mandate: Legislation must pay for itself or across-the-board spending will be cut. These cuts would hit community oncology practices hard, challenging the viability of their operations and reducing their ability to support patients who turn to them for convenient, affordable, and specialized care.

In the face of these impending regulatory and legislative complexities, the onus falls on community oncologists to advocate for themselves and their patients, be leaders in value-based care, and be more transparent and accountable. Since the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, oncologists have become more politically active, but there is still a long way to go. Many regulators do not understand the benefits of community oncology or how Medicare Part B changes affect these practices. By defining their value to legislators, community oncologists would gain support and be less vulnerable to lobbies whose interests are on the other side of the table.

When oncology practices speak as one, policy can change. The Medicare Part B prescription drug model is a prime example. The experiment was intended to limit spending on cancer treatments administered in outpatient settings, including chemotherapy and biologics. In May 2017, the Community Oncology Association (COA) submitted a formal letter requesting cancellation of the program, citing its negative impacts on patients—specifically, the elderly&mdash;and community providers. By November, the experiment was abandoned. This type of concentrated effort will help enact meaningful change that allows physicians to continue providing the highest-quality care.

Many resources can guide oncologists who want to educate themselves on the issues shaping the future of their care. The advocacy program Community Counts

 provides information on regulatory issues affecting community oncologists. Professional societies such as COA, the American Society of Clinical Oncology, and the Association of Community Cancer Centers are also fantastic hubs for information.

In addition to keeping abreast of regulatory changes, physicians must learn how to operate more transparently. For example, electronic practice management and clinical systems can streamline business. Electronic practice management systems automate the billing, claim processing, revenue management, and reporting functions that would ordinarily be performed manually by staff. The time saved can be used to focus more on patient care. However, to best implement these tools, providers need to apply pressure to vendors and regulators who control data sharing so that interoperability and standardization evolve to fit the needs of community practices. As this happens, these tools will help improve conformance with treatment guidelines and policies on payment. Also, by having data at hand, practices can clearly see where payment gaps exist and work to close them.

The technological resources available now are breathtaking. Clinical decision-making, cost-management, and revenue-management tools are critical resources for evaluating a practice’s overall health. Resources such as Innovation Cancer

 connect practices to critical technology that can review and monitor inventory, payer contracts, and treatment regimens, providing a critical level of support to practices.

In this new era of value-based care, community oncologists should champion for models of value and cost-effectiveness that help them become more efficient and viable. These healthcare professionals are uniquely positioned to be leaders in valuebased care, as their deep ties to the communities they serve allow for more streamlined management of care. Initiatives like the Oncology Care Model (OCM) use financial incentives to promote high-quality, coordinated care. The Center for Medicare & Medicaid Innovation is creating additional pilots that would save money for Medicare and Medicaid, and there is opportunity for community oncologists to opt in early. By participating in the OCM and other value-based care models, community oncologists can address patient needs and be paid appropriately for the care they provide.

While questions around Medicare Part B cuts and the tax bill’s impact may make the forecast for community oncologists seem bleak, opportunities do exist. Community oncology continues to be a positive driver in the evolution of new payment models and programs. This year, we expect to see the results from the OCM program and find out whether it becomes more widely adopted. With new and innovative treatments in the pipeline, community oncologists will play a significant role in how these therapies will reach patients. By continuing to advocate for themselves and become more efficient, transparent, and accountable, community oncology practices can continue to stand as vital resources for high-quality, lower-cost care in their communities.

Community Oncology Alliance. Fact sheet: what is community oncology? COA website. communityoncology.org/wp-content/uploads/2017/08/What-is-Comm-Onc.pdf. Published 2017. Accessed February 18, 2018.

Community Counts. communitycountsadvocacy.org. Accessed February 18, 2018

Innovation Cancer. innovationcancer.com. Accessed February 18, 2018.

Independent community oncologists play a vital role in cancer treatment for hundreds of thousands of Americans.

Barry Fortner, PhD

Articles

Community Practice Provides Model for Finding New Revenue in COVID-19 Era

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