The 114th Congress has made fixing the Sustainable Growth Rate (SGR) formula, which is a method used by the Centers for Medicare and Medicaid Services (CMS) in the United States to control Medicare spending on physician services, a priority but the question about how to pay for it remains. There’s widespread agreement on both sides of the aisle that Medicare’s payment system needs to be replaced— that’s a good start, considering the current emergency spending authorization, or ‘patch’ is set to expire on March 31.

Stop me if all this sounds vaguely familiar.

You’ll recall that Congress came close to coming up with a solution when the House passed the SGR Repeal and Medicare Provider Payment Modernization Act (HR 4015) in March 2014. But it died in the Senate because there was no consensus on how to fund the fix.

Nonetheless, members of House Energy and Commerce Health Subcommittee, which met this past January 21 and 22, seem to be optimistic that a fix can be found.

In his opening remarks, the chairman of the subcommittee, Joe Pitts, (R-PA), called finding a permanent replacement for SGR the paramount issue facing the health panel. “This subcommittee has made permanent repeal of the flawed SGR a top priority for the last 4 years. In 2014, we reached a bipartisan, bicameral agreement on a replacement policy that enjoys widespread support both in Congress and among the stakeholder community,” he said.

“We’ve got the bill, we’ve got a draft, we’re ready to go,” said Rep. Michael Burgess (R-TX) after the hearing on January 21. Burgess is an obstetrician who authored HR 4015. “All it takes is us agreeing to the offsets.”

A permanent repeal would cost about $118.9 billion. Rep. Gene Green, a Democrat from Texas, said the figure was the cheapest he’d seen since the SGR was created. He also said that he wanted a fix but not at the expense of physicians or patients.

Calling for expediency, Rep. Frank Pallone, a New Jersey Democrat, said, “After this hearing we should wait no longer to roll up our sleeves and get down to the work of ensuring that the bipartisan and bicameral bill agreed to last year is enacted into law.”

Pallone is the ranking minority member on the full Energy and Commerce Committee.

Pitts noted that any repeal of the SGR won’t get very far unless lawmakers include spending cuts to pay for the fix. “As a practical matter, the House leadership has said bills must be offset before they can be heard on the House floor,” Pitts said.

The SGR formula was created in 1997 and ties Medicare’s payment rates for doctors to the projected growth of the national economy. But as spending outpaced economic growth a multibillion dollar gap arose in funding for Medicare. Last year’s ‘patch’ was the17th that Congress passed.

In other news, I want to encourage each of you to take a few minutes and nominate a mentor, colleague, or researcher who you believe would be a worthy recipient of the 2015 Giants of Cancer Care award. The prestigious award is bestowed upon the best and brightest oncology heroes whose groundbreaking contributions to the field have improved the lives of patients with cancer.

Cast your vote today at http://giants.onclive. com/nominate.

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There's widespread agreement on both sides of the aisle that Medicare's payment system needs to be replaced-that's a good start, considering the current emergency spending authorization, or â€˜patch' is set to expire on March 31.

Congress Optimistic About an SGR Fix; Vote Now for the Giants of Cancer Care

Safe medication management is a crucial aspect of patient care. That’s especially true in patients with cancer who are particularly vulnerable to medication mishaps, given the high-risk nature of the medications used in their treatment.

To address this concern, the Institute for Safe Medication Practices (ISMP) and the Institute for Safe Medication Practices Canada (ISMP Canada) worked collaboratively to create a self-assessment tool to assist oncologists in evaluating safe practices related to medication use. The final version of the tool consists of 175 self-assessment items, according to the study published in the 

“This tool will allow community oncologists to conduct their own risk assessment,” said Carole R. Chambers, BSc(Pharm), MBA, of the International Society of Oncology Pharmacy Practitioners (ISOPP) and one of the authors of the study. “The assessment provides the known risks and allows the oncologist to see where he stacks up against his peers.”

Oncology practice in most developed countries is similar, she went on, so testing the tool internationally to determine how well it performed and how well it was received was an added benefit.

Previously, ISMP and ISMP Canada had created medication safety self-â€¨assessments for acute care hospitals. After conducting low-level surveys of their membership, it became apparent that “practice management techniques in oncology were pretty congruent.”

In addition, adverse outcomes associated with chemotherapy errors have been widely reported in the literature and the media. For example, according to the World Health Organization (WHO), administration of vincristine via the intrathecal route instead of the intended intravenous (IV) route is known to have occurred 55 times worldwide between 1968 and 2007.

 Anecdotal reports have suggested that the actual number of misadministration incidents involving vincristine had reached 120 by 2014. Intrathecal administration of vincristine results in ascending myeloencephalopathy, causing severe pain, paralysis, coma, and, in most cases, death.

In 2006, a patient in Canada received an infusion of high-dose fluorouracil over 4 hours that was intended for administration over 4 days. The patient died about 3 weeks later.

These and other examples spurred the need for, and development of, an assessment tool to assist oncologists in identifying best practices for the safe use of oncology medications. The self-assessment tool was tested in a small number of international oncology practice settings before being launched online.

A self-risk assessment would be particularly helpful in oral chemotherapy. According to the study authors, fewer than half of the participants in the analysis indicated that safeguards for oral chemotherapy and biotherapy agents were similar to those in place for parenteral agents.

Regional results also play a role in safeguard practices, said the authors of the study. For example, 68.4% of respondents from Asia, Europe, and South America combined had safety-related processes in place, compared with 41.3% of United States respondents who reported similar safety practices.

According to the study, a misperception exists, however, on the part of both practitioners and patients that oral chemotherapy agents are safer than parenteral agents.

“The oncology market is moving towards the use of more oral chemotherapy medications. Safety risk assessment is becoming more relevant to the community oncologist,” Chambers said.

With traditional IV medications, the patient arrives at the infusion center for a weekly or monthly treatment. Dosing, monitoring, and all safety precautions are in place in the infusion center and the staff is prepared for any unexpected emergencies. But the situation changes with oral chemotherapy because the patient is now in control of when, where, and how the medication is handled and taken.

“The literature is starting to come out now—if you don’t have good adherence or compliance with your ordered dose, you may not get the disease outcomes that you are expecting,” Chambers said. It is easy for patients to misunderstand how they are supposed to take the medication, with the real possibility of increased toxicity and harm from errors.

The other concern with prescribing oral chemotherapy agents is that, unless there is a robust monitoring system in place, patients may not contact the physician’s office if they start experiencing side effects.

“You have the possibility of people going off the rails quicker than you would if patients were coming in for routine appointments,” Chambers warned.

The self-assessment tool is available on the ISMP Canada web site: 

“Oncologists can go online and take the assessment and compare their findings to a baseline to see how their practice relates to everyone else’s practice,” Chambers said.

It is clear that patients are at risk for serious harm if high-alert medications such as chemotherapy and biotherapy agents are involved in medication incidents. Specific safety strategies, such as those proposed with the self-assessment tool, should be implemented to prevent such harmful events from occurring.

“When we talk about safety, I would prefer to mitigate risk, to take the steps proactively to minimize risk, rather than be in a reactive state when patient harm does happen,” concluded Chambers.

		Greenall J, Shastay A, Vaida AJ, et al. Establishing an international baseline for medication safety in oncology: findings from the 2012 ISMP international medication safety self-assessment for oncology. 

		Information Exchange System alert no. 115. Geneva, Switzerland: World Health Organization, http://www.who.int/patientsafety/highlights/PS_alert_115_vincristine.pdf. Accessed January 25, 2015.

		Burgess N. High-risk medication alert for vincristine injection. Appendix 3: literature review. 

Collingwood, Australia: Society of Hospital Pharmacists of Australia Federal Secretariat,

		Fluorouracil root cause analysis report. Toronto, ON: Institute for Safe Medication Practices Canada. http://www.ismp-canada.org/download/reports/FluorouracilIncidentMay2007.pdf. Accessed January 25, 2015.

		Fluorouracil root cause analysis: follow-up. 

 2007;7:1-4. http://ismp-canada.org/download/safetyBulletins/ISMPCSB2007-04Fluorouracil.pdf. Accessed January 25, 2015.

The Institute for Safe Medication Practices (ISMP) and the Institute for Safe Medication Practices Canada (ISMP Canada) worked collaboratively to create a self-assessment tool to assist oncologists in evaluating safe practices related to medication use. 

Oral Chemotherapy Use Benefits From Safety Self-Assessments

The New Year offers little hope of breakthrough software improvements for medical practices, but experts say oncologists can still make 2015 a time of breakthrough productivity gains.

Most practices can get far more from existing tools and personnel—if they take the time to systematically analyze their workflow, eliminate obviously counterproductive practices, and experiment with potential improvements.

“There is no magic bullet. Substantial improvement takes real effort, but it’s worth it,” said Owen Dahl, a consultant with Medical Group Management Association. “Small improvements add up. Many offices can increase overall efficiency by 10% or more. That’s like adding 2 free workers to a staff of 20,” Dahl said.

Many practices, for example, can save time by making better use of online portals that allow patients to view test results and communicate with doctors, nurses, and staff.

The basic technology arrived a decade ago amid predictions it would delight patients and practices alike. Patients would get an easier way to pay bills, manage appointments, view test results, and request refills. Practices would get a system that streamlined (and eventually automated) those time-consuming tasks and eliminated the need to call patients about upcoming appointments.

Only a few studies published to date measure such claims against reality, but such studies generally find that patient portals actually deliver much of what they promise.

A much-cited paper published a decade ago in the Journal of General Internal Medicine compared 6 primary practices that bought early portal software with 9 that did not. It found that offices with portals typically dealt with 13.7% fewer patient contacts than offices with no portals (P = .025).

Portal technology has improved since then and people feel more comfortable communicating online. Newer reports from individual practices seem to reflect these trends. They typically suggest that robust portals and aggressive efforts to get patients using those portals can decrease practice call volume by 30% or more.

Yet many oncologists have yet to roll out portals with the sort of functionality that truly reduces (or eliminates) the time staff members must spend on a wide variety of activities. Their ‘portals’ are little more than glorified e-mail systems that let patients view some records online.

Many other practices pay vendors for portals but fail to notify patients about their availability. Federal records indicate that a solid majority of medical offices now offer some sort of portal, but a 2014 survey by the consultancy Technology Advice found that less than half of all patients realized that their doctors provided such a service.

Patients obviously cannot serve themselves when practices fail to give them the necessary tools or to make them aware of those tools, but offices that want to maximize self-service must do more than buy and advertise good portals. Case studies suggest that enrollment drives are the key to portal use. “Practices that sign patients up and walk them through the portal while they’re actually in the office can often get enrollment rates over 50%,” said Elizabeth Woodcock, a consultant who has written several books about managing medical practices.

“But practices should not push enrollment at all until they offer a quality portal that gives patients an easy way to do a number of things. Most people will only test your portal once, so it’s counterproductive to send them to the sort of placeholder portal that has little functionality.”

Other communication technologies can also boost worker productivity.

Most oncologists already have software that sends prescriptions directly to pharmacies and retrieves laboratory results directly from testing companies, but published research and case studies alike suggest that all practices should push themselves to use such programs whenever possible.

Some might object that electronic prescriptions take longer to write than paper prescriptions—and although some published studies disagree, others support this intuition&mdash;but research that also measures follow-up calls from pharmacies concludes the software saves time.

Indeed, a Medicare study from 2005 estimated that pharmacies call doctors with questions on 30% of all written prescriptions. Good software, on the other hand, makes it pretty hard to write an ambiguous prescription.

Seamless communication between medical offices and pharmacies has stoked demand for seamless communication between electronic health records (EHRs) among various medical offices. The ability to share patient records (with patient consent, of course) would obviously save all practices a tremendous amount of drudgework, and it will come—some day.

Some have actually predicted that 2015 will be the year of EHR ‘interoperability,’ and such predictions may come true, in the sense that 2015 may be the year the federal government effectively forces vendors to start working seriously in that direction, but most observers doubt that 2015 (or 2016) will see the actual EHR upgrades that make seamless data transfers a reality.

There are, however, some immediate options for practices that want to share more patient information with more organizations. If those practices operate in a market that’s dominated by a single health system, they can adopt whatever EHR the dominant system uses. If they operate in markets with no dominant providers, they can adopt whatever EHR sells best in their area.

Switching from one EHR to another currently ranks among the world’s least pleasant activities—some say vendors intentionally keep their systems incompatible to lock in customers&mdash;but it can pay off for operations that made poor initial choices. EHRs vary widely, not only in their ability to communicate with other software, but also in their underlying functionality.

Some systems, according to consultants who frequently work with oncologists, offer many more cancer-focused features than others.

The worst systems, for example, hardly acknowledge that oncologists often buy and administer medications, rather than just send patients to the pharmacy. The best start with each patient’s long-term treatment plan and attempt to take it from there: using records on patient weight to determine how much medication each patient will need at each visit, ordering those medications so they arrive just in time, reminding patients when they need to come in, giving each nurse daily instructions for each patient, and then billing patients.

Such ambitious systems do have their glitches, they tend to be expensive, and they often require more human intervention than originally expected, particularly when staff members begin to use them. For any practice that really wants to boost productivity, however, they do merit consideration.

Another practice that merits consideration, at least for practices that manage some patients on a fee-for-outcome rather than a fee-for-service basis, goes by the name of ‘asynchronous communication.’

At its most basic level, the term encompasses any form of back-and-forth that doesn’t require providers to respond to patients in real time. Simple e-mail technically qualifies as asynchronous communication, and advocates of the practice initially hoped that something so basic could boost productivity at doctors’ offices.

E-mail generally fulfills those hopes in simple cases where providers can resolve an issue with a single e-mail. Office workers set aside a certain time for e-mail and speed through a crowded inbox rather than getting randomly interrupted by the phone.

The benefit of e-mail declines, however, as exchanges grow longer. A 10-message ‘conversation’ with patients about a relatively complex topic takes caregivers more time than a single phone call. (This problem explains why basic patient portals that essentially exchange phone calls for e-mails save time for some things but not others.)

The problem with e-mail became apparent around the same time that separate research demonstrated that doctors performed as well, but saved no time at all, when they substituted face-to-face visits with videoconferences.

Shortly thereafter, researchers from Massachusetts General Hospital devised a concept they called the ‘virtual visit.’ Rather than using videoconferences or face-to-face meetings for routine follow-up consultations, they began sending patients questionnaires that covered all the relevant topics. Patients responded at their convenience. Doctors then reviewed those responses and took whatever steps they would have taken at an actual appointment.

“We have done this with several thousand patients now, and the results have been striking,” said Ronald F. Dixon, MD, director of the Virtual Practice Project at Massachusetts General Hospital’s Department of Medicine.

“Patients and clinicians both tend to enjoy virtual visits because they provide the same quality of care in far less time than face-to-face visits. On average, clinicians spent about 18 minutes per patient doing these visits in person and then documenting them afterward, but just 3.5 minutes per patient with virtual visits. Some of that stems from the fact that reading is faster than talking. Some stems from the fact that patients do most of the documentation themselves by filling out the questionnaire,” Dixon said.

Dixon believes that many oncology practices already have all the tools they’d need to begin a virtual visit program and that the system would work particularly well for them. Indeed, the very idea of virtual visits occurred to Dixon while he was shepherding his father to a seemingly endless series of routine follow-ups with his oncologist.

“I know my father valued the relationship he had with his oncology team — but if there was a way that he could replace some of his visits with that trusted team in a more convenient way, then he would have jumped at the opportunity.”

The biggest obstacle that Dixon sees is financial. Health insurers have generally declined to compensate doctors for asynchronous virtual visits. Some insurers will pay for the service, however, and doctors who get paid by the patient rather than the visit have every incentive to experiment with potential money-savers. Such experiments need not involve revolutionary technology or revolutionary ideas.

Consultants who work with doctors say they can often achieve double-digit productivity gains by eliminating obviously counterproductive habits that arise by chance and endure because no one ever stops to consider them.

For all specialties, nurses spend several minutes asking questions and writing down answers for the doctor who then ignores what the nurse wrote and asks the patients all of the same questions a second time.

Many oncology practices refuse to schedule a first visit with a patient until they receive patient records (which usually takes 3 to 5 days to arrive), scheduling the appointment from information the patient provides directly, and making adjustments in those few cases when the records necessitate some sort of change.

For all specialties, practices try to minimize the time they spend waiting for patients by planning to see them slightly after their scheduled appointment times. Patients retaliate by coming late. Practices respond by delaying more. The very concept of time eventually becomes virtually meaningless and everyone suffers.”

Not every office makes these particular mistakes, but nearly every practice makes these types of mistakes because the people who run them care more about medicine than workflow analysis.”

“We find that at least of quarter of every employee’s effort at a typical small practice is utterly wasted—meaningless at best, actively counterproductive at worst,” said Dahl. “That sounds terrible, but practices should view it as an opportunity. Substantial improvement is very possible.” ”

February 2015 | Oncology Business News®

Congress Optimistic About an SGR Fix; Vote Now for the Giants of Cancer Care

Oral Chemotherapy Use Benefits From Safety Self-Assessments

Improving Practice Efficiency Through Emerging Technologies