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Community Oncology Conference

Patricia J. Goldsmith, chief executive officer, CancerCare, previews data of a CancerCare study highlighting some of the financial challenges associated with patients who have cancer.

Financial support is one of several components that CancerCare provides to patients, Goldsmith explains.

A landmark study that will be published by CancerCare in May 2016 showcases the demographics of 3000 patients with cancer in the United States, as well as the financial challenges they face. This will help to provide insight to community oncologists, Goldsmith says.

In a preview of the data, she adds, patients under the age of 64 reported a monthly average of $1112 out-of-pocket costs to cover medication, co-pays, deducibles, and transportation expenses related to their cancer treatment. 

Patricia J. Goldsmith, chief executive officer, CancerCare, previews data of a CancerCare study highlighting some of the financial challenges associated with patients who have cancer. 

Patricia Goldsmith on Financial Stress Associated With Cancer Care

David Eagle, MD, past president of the Community Oncology Alliance (COA) and partner in Lake Norman Oncology, Mooresville, North Carolina, discuss controlling costs of cancer treatment.

The first step to understanding how to control cancer costs is to understand where money is being spent and why, says Eagle.

Between 2004-2014 the rate of increase of per patient per year spending for those actively receiving cancer treatment was no different than the non-cancer patient population. This was surprising because there has been so much innovation in oncology recently, says Eagle.

The migration of oncology treatments from private practice to hospital outpatient services has also been a major cost driver, says Eagle.

If these patient services had stayed in the private practice instead of migrating to hospitals, Medicare would have saved 2 billion dollars in 2014, predicted Eagle.

Dr. David Eagle on Cost-Drivers in Oncology

Stephen S. Grubbs, MD, senior director of the new clinical affairs department of the American Society of Clinical Oncology (ASCO) discusses value-based oncology.

The field of oncology is moving toward a value-based system, where doctors will be gauged on the value on their care instead of individual components, says Grubbs. In the past oncology has mostly been a fee-for-service model.

In order for a value-based model to work, it must first be determined how value can be measured, he says. There must be a structured approach to how value will be measured in the long run.

ASCO is putting together a framework to determine how to define value. There is currently a framework that has been published, which is open for consideration, says Grubbs.

Dr. Stephen Grubbs on Measuring Value in Oncology

Members of the Community Oncology Alliance (COA) have issued a call to arms to spur a greater lobbying effort to stop a plan by The Centers for Medicare & Medicare Centers (CMS) to implement a drug reimbursement change under Medicare Part B. The proposal to adjust payments by limiting markup on drugs purchased for administration to patients is poorly thought out and could do harm to patients, the group contends.

CMS is viewing this as “an experiment or a test upon practices, and it really is an experiment on patients. They have no mechanism to measure outcomes, and this is really concerning,” said Shelagh Foster, JD, senior director of advocacy for ASCO. Foster joined a panel discussion on the subject at the 2016 Community Oncology Conference this week in Orlando, FL.

The proposal from CMS would trim the Average Sales Price (ASP) plus 6% markup to ASP plus 2.5%, and it would establish a flat fee rate to augment those payments, but oncologists have said they’re already losing money or making only marginal sums on certain drugs. They say sequestration cuts and discounts already applied to Medicare payments further eat away at their profitability, while storage, handling, and other expenses also take a bite out of their drug sales business. They have said the CMS plan could affect their treatment choices for patients, thereby affecting outcomes.

The panel discussion at the COA meeting amounted to a full-blown dissection of the Medicare Part B proposal. However, commentary about the plan slipped into many other segments of the conference agenda, as the proposal is viewed as a major threat to community oncology practices in particular. Hundreds of groups and associations—not just oncology sector entities&mdash;have registered their opposition to the plan in letters to CMS and to their elected representatives.

Panelist Brad Tallamy, who serves as director of government affairs for the drug wholesale company Amerisource Bergen, said that he and others have spent the past 3 weeks in Washington working exclusively to persuade legislators to oppose the CMS initiative. He said elected officials are under siege on this issue.

He said legislative staffers have requested that oncologists provide them with specific examples of how the quality of treatment would be compromised under the payment change.

“They want specific examples of patients diagnosed with disease X, or standard of care versus treatment Y, and there is not a generic equivalent, or the brand is standard therapy. They want a comprehensive list of situations so they can go to [CMS] and say, ‘What are oncologists in all of these situations supposed to do?’ Because, under the model, they’re going to be under water on these drugs,” Tallamy said.

Medicare has described the proposed payment revision as a way to get better value for Medicare patients. Drugs included under the plan would include intravenous infusions, injectables, and other drugs that require a medical professional to administer. The proposed system would result in “smarter spending and healthier people” and would better integrate care, CMS explained in a March statement. Whereas physician margins on higher-priced drugs would be reduced, the addition of flat fees would improve the attractiveness of prescribing lower priced drugs, thereby reducing a prescribing bias, CMS stated.

The public comment period on the CMS proposal, which would be implemented through the sub-entity Center for Medicare and Medicaid Innovation (CMMI), will terminate on May 9, 2016, adding to the sense of urgency. Additionally, plans for other drug price management efforts have been announced but not clearly defined, and these will be rolled out in test markets across the United States, CMS has announced.

The COA panel contended that the plan amounts to an effort to control soaring drug prices by capping physician pay. Adding to the cynicism are rumors in Washington, DC that CMS plans to exempt oncology practices that enroll in the forthcoming Oncology Care Model (OCM), according to Ted Okon, executive director of COA, who moderated the panel discussion. The OCM is a CMS-led effort to drive reform in pricing and value in oncology treatment.

“This a concern for us on the Hill,” said Foster. “They think Democrats may look at an OCM carve-out as a solution—they’re taking care of oncologists. It’s really important to explain to them why that’s not the case.”

Roughly 75 oncology practices have been informed by CMS that they are on the short list for inclusion in the OCM, according to Okon, and the next step is for them to complete additional paperwork.

Panelists urged the assembly of oncologists, practice administrators, and other healthcare workers to use available tools on oncology association websites to calculate the impact on their practices that the Medicare Part B proposal would have. They said those results should be shared with legislators and CMS in order to add additional weight to the argument against the planned revisions.

Okon said COA is poised to take legal action and has engaged the services of its law firm, which has begun an examination of executive orders relating to the CMS proposal, “which is a process of getting our ducks in a row.” No official COA board vote has been taken to pursue legal action, Okon said. “The sentiment is clearly [that legal action is] a means of last resort, but we will do it. If you let CMS use CMMI to overwrite a law—ASP plus 6%&mdash;then whoever is in the White House, whether it’s Bernie or Hillary or Trump … Donald Trump could come in and use CMMI to build a mandatory demonstration project to build his wall [between Mexico and the United States]. That’s how absurd this could get.”

View more from the 2016 Community Oncology Conference

Members of the Community Oncology Alliance have issued a call to arms to spur a greater lobbying effort to stop a plan by The Centers for Medicare & Medicare Centers to implement a drug reimbursement change under Medicare Part B. 

COA Gearing Up for Fight on Proposed CMS Payment Cut

Aligning physician compensation to performance can be a dicey matter, as it is difficult to reach a consensus on how to measure physician success. However, a number of oncology practices have been developing systems for doing this and achieving success, attendees at the 2016 Community Oncology Conference were told.

Physicians and practice administrators participated in a panel discussion on the matter during the opening day of the Community Oncology Alliance meeting. They said developing metrics that can be easily interpreted and clearly point to achievement, or the need for improvement, are critical for success at hitching compensation to value.

They said, though, that it has been an evolving process that has taken some of them years of experimentation and development—and cannot be achieved overnight. Nevertheless, they had success stories to tell and helpful tips for the physicians and administrators in attendance. They warned that the growing emphasis on value, especially by The Centers for Medicare & Medicaid Services, makes it important for other practices to embark on the same journey.

“The landscape is rapidly changing,” said Lucio Gordan, MD, of Florida Cancer Specialists & Research Institute, who moderated the discussion. “Without accurate measurements, it becomes very difficult to move forward. We have to benchmark ourselves. We have to be able to use metrics to improve care, to improve safety, to improve efficiencies, and to potentially contain costs.”

Also participating from Florida Cancer Specialists & Research Institute,—a group of over 90 practice centers encompassing 50% of the Florida oncology market&mdash;were Michael Diaz, MD, and Todd Schonherz, chief operating officer. Other participants included Randy Broun, MD, president and chairman of Oncology Hematology Care (OHC) of Cincinnati, which has 20 locations in Ohio, Kentucky, and Indiana; and Richard Schiano, CEO of OHC.

Broun said that OHC began a multi-year transition to evaluating the quality of its work in 2012 by bringing in an outside consultant. That led to a complete redesign of their physician compensation system. They created various performance scales that would apply to the different departments within their practice, and physicians were evaluated based on how well their actions stacked up against those measures.

A total of 5% of physicians’ compensation was placed “at risk” in terms of their obligation to fulfill these expectations, Broun said. Each department participated in the development of some of the measures and, overall, the practice added additional metrics, such as patient satisfaction and compliance with guidelines.

“Those were monitored and applied, and at the end of the day, the 5% was awarded or not,” Broun said. Care was taken to establish a set of targets that were achievable, he said, and most of the physicians have been successful.

Even so, an enormous amount of data has to be collected to provide useful information that can aid in this process, Broun said. Practice administrators had to be prepared to argue in the event a physician disagreed with their assessment of his or her performance.

“Virtually every time somebody didn’t achieve the level they were supposed to, it was the data’s fault, and so they would be stomping into [the administrator’s office], pounding on his desk, saying, ‘Well, your numbers are wrong.’ And he’d say, ‘Show us.’”

Diaz said his group has taken a go-slow approach to tying physician performance to compensation. “One of the approaches we’ve taken at Florida Cancer Specialists & Research Institute, is developing the appropriate infrastructure so that physicians have all the tools there to be able to deliver optimal quality and value. We’re still trying to define value and quality—all of the measures. The last thing we want to do is focus in on moving targets.”

Schonherz said that Florida Cancer Specialists & Research Institute, has taken the discussion about value-based reimbursement to payers and that it takes a great deal of work to arrive at common measures. “These are not just simple agreements that we enter into: what’s in, what’s out, what’s capped, how do you handle inflation, and what about new drugs?” He said this will remain a work in progress for some time to come.

Payers that OHC works with have embraced the physician compensation program at OHC, and the practice is now looking to align its guidelines for performance with some of the things that payers are asking them to do, Broun said.

Problems were encountered in 2014 when OHC adopted a new EMR platform for recording and interpreting data and it wasn’t appropriate, which led the practice to temporarily abandon the effort. “It didn’t allow us to track the things that we wanted to track, so rather than being arbitrary and diminish what we were trying to achieve, we suspended our look at quality measures,” he said.

Patient perceptions of care were described as paramount and also as a collective tool that could be used to inform and motivate physicians.

Schiano said OHC has been using a consumer survey tool called Net Promoter that helps to determine whether your customers will grouse about your business or talk about it enthusiastically.

“What research has shown is that if somebody is a Net Promoter, they’re an advocate for you,” Schiano said. “They’re very difficult to dissuade, they’re a believer in your practice, and they will champion your cause. The long-term value to your practice is significant. We do these surveys on every billable that comes into the practice, and we score our physicians. We establish a number they can look at, and when the doctors see those numbers, due to their competitive nature, they want to deliver increased satisfaction to their patients. They want to be on the top of their game, and that ultimately is delivering value to the patient, but also value back to the practice. As we move forward, we’ll continue to build on that.”

The numbers that come of the metrics and survey tools should not be a closely guarded practice secret, the panelists said. The more transparency there is, the more likely other employees besides doctors are likely to recognize the need to try harder.

“My vision is that in each practice site, the entire practice is aware of how we’re performing in terms of patient satisfaction,” Schiano said. ”How you do that is you literally put the numbers up on your bulletin board each week. You have morning huddles with your staff. You have that level of transparency there, so that it becomes ingrained in the practice beyond the physician, because if the physician is doing it but the person at the front desk who’s doing the checking-in isn’t doing it, you’ve diminished everything you’re trying to achieve.”

Ultimately, a practice has to be forward-looking so that it has performance measuring systems in place and working successfully, because the demand for these will only increase, panelists agreed. Not only that, armed with reliable statistics on the value of its medicine, a community oncology practice’s bargaining power with payers and its ability to justify itself as a value-based operation will be enhanced, they said.

“You can’t meet the CMS guidelines unless you have the analytics to demonstrate that you’re performing. This is tough and—let’s be clear&mdash;this is a cost that we all have to bear to build that architecture and to ensure that we have the capability in our people to extract that data and to be able to give it to the various payers. That’s not an overnight mechanism,” said Diaz.

Aligning physician compensation to performance can be a dicey matter, as it is difficult to reach a consensus on how to measure physician success. However, a number of oncology practices have been developing systems for doing this and achieving success.

Aligning Physician Compensation to Value Is No Easy Task

Biologics therapy spending soared several hundred percent from 2004 to 2014; but despite rising treatment costs in general, oncology spending kept pace with spending for all categories of medical care, according to a report on Medicare and commercial data from the Community Oncology Alliance (COA).

“There has been a long-held belief in research and policy circles that cancer care costs in America have gone up disproportionately as compared to other health care costs,” said Debra Patt, MD, MPH, MBA, a practicing oncologist at Texas Oncology and a COA board and study team member. “This study shows that this commonly held belief is not supported by the evidence.”

The study by Milliman, a global actuarial and consulting firm, also noted a dramatic shift in site-of-service for chemotherapy infusion from community oncology centers to more expensive hospital outpatient departments, which has added to the rise in the cost of cancer care overall.

		Table 1: Infused chemotherapy drug spending by site of service

Source: Based on Milliman analysis of the 2004-2014 Truven MarketScan data and Medicare 5% sample data

For example, whereas roughly 90% of commercially insured chemotherapy infusion was done in physician offices in 2004, by 2014 nearly 60% of commercial infusion was being done in hospital outpatient centers, according to the report 

. The report estimated that Medicare would have saved $2 billion had there been no change in site-of-service for chemotherapy infusion from 2004 to 2014.

Various categories of oncology care spending went up dramatically, according to the report, which distinguished between Medicare and commercial payer spending on these items. From 2004 to 2014, Medicare spending on emergency department care rose 132%, whereas related commercial spending was up 147%. For radiation oncology the respective numbers were 204% and 66%; and for biologic chemotherapy, 335% and 485%

Among the less dramatic increases were hospital inpatient admissions, which saw a 22% increase in Medicare spending versus 44% commercial; and cytotoxic therapy up 14% and 101%, respectively.

		Table 2: 2004 to 2014 allowed cost trend by major service category for actively treated patients — Medicare and commercial

While drug spending was up sharply, it amounted to just one-fifth of total costs among actively treated cancer patients in 2014, the report said. Therefore, overly focusing on drug costs in the effort to reduce overall oncology spending would be a misguided strategy, said Ted Okon, executive director of COA. The report comes out just shortly after The Centers for Medicare & Medicaid Services announced a plan to modify physician reimbursement for Medicare Part B drug expenses. Okon said the findings are evidence that the proposed adjustment to payment rates would add to the difficulties of running an independent oncology practice and accelerate the trend of consolidation among cancer treatment centers that is contributing to higher costs of care.

Okon said the report shows that more attention needs to be paid to the use of radiation therapy, given that the increase in spending in this category was among the highest of those looked at. “I think we have to do a better job in general of making sure all of that is appropriate use.” An evaluation also needs to be made of emergency department use, given the findings, Okon said.

The report included an analysis of site-of-care payment differences between outpatient centers and independent oncology clinics offering chemotherapy infusion. The report cited a $6,500 lower cost on average for Medicare beneficiaries receiving chemotherapy infusion at a physician’s office versus a hospital outpatient setting.

While the cost of drugs is not solely at fault for the rising cost of cancer care, there has been a plethora of new drugs approved and new indications approved for existing drugs, all of which has contributed to rising expense, the report noted. Over 70 new drugs and biologics were approved for cancer indications over the 11 years of cost data looked at by Milliman. “In each of the past three years, more than 20 therapies have been either approved to treat cancer or received new cancer indications,” the report said.

In addition, patient survival rates are increasing, which also leads to greater, long-term treatment costs, the report said, citing the example of treatment for multiple myeloma, for which the 3-year survival rate was 42% during the 1980s and climbed to roughly 66% in the 2000s with the introduction of thalidomide analogs and proteasome inhibitors.

Over the 11 year study period, patient costs increased 35.2% for the Medicare population, 36.4% for the actively treated cancer population, and 34.8% for the noncancer population. For the commercially insured, the cost increases were 62.9% for the total population, 62.5% for the actively treated cancer population, and 60.8% for the noncancer population.

Also among the findings, the prevalence of cancer increased between 2004 and 2014 from 7.3% to 8.5% (a 16% increase) in the Medicare fee-for-service (FFS) population and from 0.7% to 0.9% (a 26% increase) in the commercially insured population, according to the study. However, the prevalence of actively treated cancer remained relatively stable for both populations: 2.7% in 2004 and 2.6% in 2014 for the Medicare FFS population and 0.4% in both 2004 and 2014 for the commercial population.

The report was commissioned by COA and received supportive funding from the pharmaceutical industry, including Bayer, Bristol-Myers Squibb, Eli Lilly and Co., Janssen Pharmaceutica, Merk, Pfizer, Takeda, and the Pharmaceutical Research and Manufacturers of America.

A full copy of the study, methodology and detailed appendices is available on the COA website at 

Biologic chemotherapy spending soared several hundred percent from 2004 to 2014; but despite rising treatment costs in general, oncology spending kept pace with spending for all categories of medical care.

Cost of Biologics Therapy Soars Above Other Cancer Expenses

When it opens next month at the prestigious Lowes Royal Pacific Resort, the 2016 Community Oncology Conference, Innovation in Cancer Care: Moving From Theory to Practice, from April 13-15, will feature an expanded lineup of clinical presentations, part of an effort to attract more oncologists and other clinically minded healthcare personnel to this annual event, which has traditionally been more focused on the business of running an independent practice.

Lucio N. Gordan, MD, of Florida Cancer Specialists & Research Institute, a co-chair of the Community Oncology Alliance (COA) conference this year, has worked hard to expand the clinical offerings, recognizing the attraction they have to physicians and other clinical workers in the oncology profession. “Having a dual meeting serves two purposes. We were able to recruit a top-notch faculty for the clinical track, so I’m very happy,” Gordan said.

However, the conference will retain its uniquely strong business content, with special emphasis this year on the Medicare changes up ahead that involve participation in cost-saving models that deliver more patient value, and with an additional focus on some of the incentive systems that physicians in the oncology field tend to say give them the most cause for concern about this new wave of adjustment.

Something new on the horizon that COA also is responding to in this year’s conference lineup is a segment on employers stepping up to ensure that their employees are well covered. More employer involvement in payment issues is a transformation that has taken root and will make a difference in the way practices receive their payments, said conference co-chair Robert Baird, CEO of Dayton Physicians Network of Ohio.

“The conference has changed and reinvented itself every year, in relationship or in accordance with the healthcare landscape, payment reform, legislative changes, patient care initiatives, and the quality initiative,” says Baird. “The big issue this year is that everybody is going to be impacted by the changes in Medicare. Being the largest payer in the country, Medicare can really drive a lot of policy.”

The growth of patient advocacy has long found a champion in COA; presentations on Capitol Hill issues and how patients and advocates can step up and support their community oncology practices are plentiful on this conference slate, as in previous years. The goal has always been to involve patients, advocates, physicians, nurses, and business administrators in this annual event with a balanced roster of offerings, says Ted Okon, executive director of COA.

Baird’s own practice has established a COA Patient Advocacy Network (CPAN) group. A nurse educator and patient advocate, along with some patients, will be heading down to Orlando, Florida for the conference, as well. “CPAN is really teaching patients how they can help other patients in their market or region to work together to support community cancer care,” says Baird.

Quite often a patient who has come to appreciate the service and quality available at a community practice will return that investment of hard work and dedication by putting a public face on his or her recovery, says Okon.

Such is the case of this year’s keynote speaker, Joan Lunden, special correspondent for NBC’s Today Show, who in 2014 revealed on Good Morning America that she had triple-negative breast cancer.

Lunden will be introduced by Tracey Weisberg, MD, of New England Cancer Specialists, where Lunden was treated during her struggle with breast cancer.

Look for complete coverage of the clinical, business, and advocacy programs at this year’s COA Orlando conference by the 

 news team. Stories will be posted on OncLive.com and AJMC.com; expanded coverage will be available in various MJH Associates print publications following the 3-day event.

On the clinical side, the emphasis is on the latest advances in the research field that can be applied in practice. Key areas to be covered during the conference include chronic lymphocytic leukemia, non—small cell lung cancer, gastrointestinal cancers, multiple myeloma, and melanoma. A forward-looking segment will provide a rundown on advances in immunotherapy that are just ahead.

“We broadened the clinical track just to bring the cutting-edge research results to the audience, so it’s a more encompassing theme as compared to the previous years,” says Gordan. “Coincidentally, there have been a lot of advancements in these areas not only in immunotherapy but in molecularly guided therapies for all of the topics that we picked to be discussed in this meeting. It’s very exciting.” A strong lineup of speakers will help keep the audience’s attention, among them Howard “Skip” Burris III, MD, chief medical officer and executive director of the Sarah Cannon Research Institute.

s 2014 Giants of Cancer Care award winners for his contributions to oncology, will deliver an overview of advances over the last 12 months. “Skip is very well positioned to speak on that, because he runs one of the largest clinical trial networks in the world,” Gordan said.

The conference boils down to something for everybody, organizers said, but not to be overlooked are the opportunities to meet and greet. “It’s really the place to network if you’re looking to network,” says Okon.

Practices also will find support in the array of vendors present at the conference who are eager to meet with healthcare workers and discuss products and services that can help their practices to perform better.

“We’ve got all the vendors lined up that can help practices meet these challenges, whether it’s through an electronic health record or clinical tools. There are also potentially new services and new programs that practices can implement not only to help them enhance their quality and patient care but also provide new revenue,” says Baird.

For more information about this year’s COA conference, visit 

The 2016 Community Oncology Conference, Innovation in Cancer Care: Moving From Theory to Practice, from April 13-15, will feature an expanded lineup of clinical presentations.

Community Oncology Conference | Conference