On June 30, the deadline passed for practices interested in participating in the Oncology Care Model (OCM) to submit their completed applications. Perhaps your practice was one of the more than 400 that submitted a letter of intent to participate and you are hoping to be among the 100 or so selected for the program.

The OCM is a program developed by the Center for Medicare & Medicaid Innovation (CMMI) that seeks to improve the effectiveness and efficiency of specialty healthcare through a new payment and delivery model. It requires participating physician practices that administer chemotherapy to enter into payment agreements with CMS to measure and perform on quality metrics during an episode of care. In exchange, CMS pays practices an incentive for Medicare fee-for-service beneficiaries of $160 per beneficiary per month for the duration of the episode. The program also includes potential performance-based payments that are specifically designed to encourage coordinated quality care at a lower cost during the episode.

The goal of this program is to appropriately align financial incentives to improve care coordination, appropriateness of care, and access to care for beneficiaries undergoing chemotherapy. Ultimately, these improvements are intended to result in better care, smarter spending, and healthier people. Similar programs have been under way in general practice for quite some time, and CMMI is now expanding to specialty care. So, why oncology? Oncology is an obvious first choice. The cost of treating cancer—especially chemotherapy&mdash;is highly variable, but mostly expensive. Furthermore, more than 1.6 million people are diagnosed with cancer each year, with a majority of those being over 65. Factor in the US Census Bureau’s prediction that by 2030 more than 20% of the American population is expected to be over 65, and it’s easy to see why oncology is on the radar.

CMS is not the only group to be heading down the road toward alternative payment models. At the 2015 ASCO Annual Meeting, the society announced a similar program called Patient-Centered Oncology Payment (PCOP). Their proposal is designed to simultaneously improve services to patients and reduce spending for Medicare and other payers. Likewise, many if not all private payers have similar initiatives under way. In fact, CMS is encouraging other payers to join their efforts to create a multi-payer model that would streamline transformation at the physician practices.

Practices chosen to participate in the OCM will have their work cut out for them. The program is slated to officially kick off in spring 2016, meaning that practices will need to begin to “transform” quickly to ensure they will be able to meet the performance and reporting criteria required of the program.

The addition to the practice of patient navigators who proactively monitor and perform outreach to patients is a requirement of OCM participation. It’s also clear that technology will play a vital role in enabling practices to successfully participate in this program.

Many oncology practices have already made progress in adding appropriate personnel and implementing technology solutions, such as Electronic Health Records (EHR), to enhance their ability to document and report care plans and patient event data. However, to be successful in meeting the specific criteria set forth in the OCM, most existing EHRs will need to be enhanced.

Practices must closely collaborate with their EHR vendors to clearly outline the requirements of multiple programs including Meaningful Use, PQRS, the OCM and other reimbursement models as introduced by private payers. It is important that practices are capable of participating and performing in more than 1 alternative payment model. This may require significant EHR enhancements.

Technology, necessary for successful participation in the OCM, will go beyond EHRs. For example, practices will receive claims data from payers that will be rich in information but will require analysis and interpretation. Solutions offered by McKesson Specialty Health consolidate data from internal and external sources and support practices through the entire care lifecycle, from treatment selection and administration to patient-reported outcomes, billed charges, and payer Explanations of Benefits (EOBs). These clinical, operational, and financial insights into the coordination, cost, and value of patient care can help practices in making timely and appropriate decisions, while providing comprehensive data for OCM reporting.

As many practices anxiously await the decision from CMS as to whether they have been selected for the OCM, it is clear that the way oncology practices will be reimbursed is changing. So, regardless of whether your practice is chosen for the OCM, it’s time to accept (and even embrace) change and begin taking steps toward transforming your practice.

Marcus Neubauer is medical director of oncology services at McKesson Specialty Health.

Articles

Many oncology practices have already made progress in adding appropriate personnel and implementing technology solutions, such as EHR, to enhance their ability to document and report care plans and patient event data. However, to be successful in meeting the specific criteria set forth in the OCM, most existing EHRs will need to be enhanced.


CMS Standards for Reporting Call for Advanced Technology, Training

With the cost of newer immunotherapy drugs soaring into the tens of thousands of dollars per month, payers are under increasing pressure to control spending and are tightening the spigot in various ways, oncology professionals told 

“The cost of new therapies is making them unaffordable, and the challenge for the system is, how do we distribute that cost? Is it going to be borne by higher premiums, or is there going to be more cost sharing for the individual to take the drugs?” asks Jennifer Malin, MD, a practicing oncologist and vice president of clinical strategy at Anthem Blue Cross and Blue Shield.

This month, UnitedHealthcare began requiring physicians to get prior approvals on every cancer drug they administer. The company intends to track drug outcomes by following patient progress and share that information with doctors, the 

Overall costs of cancer care in the United States amounted to $125 billion in 2010, and were projected to reach $172.8 billion per year in 2020, according to a 2011 report.

 More recently, at ASCO’s 2015 annual meeting in Chicago, costly immunotherapies were blasted as unsustainably pricey by Leonard Saltz, MD, chief of gastrointestinal oncology at Memorial Sloan Kettering Cancer Center.

Saltz noted that the combination of ipilimumab (Yervoy, Bristol-Myers Squibb) and nivolumab (Opdivo, Bristol-Myers Squibb) in metastatic melanoma, though yielding a progression-free survival benefit of 11.4 months, would cost in the neighborhood of $300,000, resulting in a $60,000 out-of-pocket cost for patients on Medicare.

When it comes to fighting back against the rising cost of cancer care, Anthem Blue Cross and Blue Shield likes to tout its Cancer Care Quality Program, a pathways initiative that Anthem says achieves the dual objectives of controlling costs and enhancing the quality of care.

“Somewhere in the neighborhood of 30% of what we spend in healthcare is waste,” says Malin. “So, can we make room for new, innovative therapies by trying to decrease what we spend in areas that aren’t bringing value and that really are wasteful? That’s what our program tries to do, by helping to identify those therapies that really do provide benefit and are cost-effective.”

Under the Guise of Sound and Efficient Medicine

While physicians sometimes suspect pathways programs of being efforts to reduce benefits under the guise of sound and efficient medicine, they are on the rise and are among a slate of endeavors by payers to counteract the rising cost of cancer care, says Scott Ramsey, MD, a physician, researcher, and health economist at Fred Hutchinson Cancer Research Center in Seattle, Washington.

“Global budgeting” for oncology is another method that, like pathways, has not fully caught on but is likely to gain traction, Ramsey says. UnitedHealthcare has already experimented with this structure wherein the insurer offers to pay a flat amount for the treatment of a patient with a certain stage disease. The payer will provide the drugs rather than reimburse the physician for them, and the fee for delivering the chemotherapy is included in the global budget.

UnitedHealthcare was successful with that program,

 and Ramsey believes “There is a high likelihood that those types of programs are going to spread.”

The 3-year UnitedHealthcare study, results of which were reported last year, paid oncologists the same fee regardless of the drugs that were administered to the 810 patients with breast, colon, and lung cancer involved in the pilot. The “bundled payment” plan was based on expected costs of standard treatment regimens for specific conditions, and resulted in a 34% reduction in medical costs, UnitedHealthcare reported. The goal was to separate the cost of drugs from care decisions.

A third type of payer response to higher costs is value-based pricing or value-based reimbursement, in which non-preferred therapies are allowed by payers but patients are then subject to higher out-of-pocket costs. Where this method falters is when the drugs, such as newer immunotherapies, are so expensive that a co-pay as a percentage of the overall drug cost is far beyond a patient’s ability to pay. “If you’re talking about a $15,000-a-month drug, that gets to be a massive barrier for patients,” says Ramsey 

		Figure. Monthly and Median Costs of Cancer Drugs at the Time of FDA Approval 1965 - 2015

Data points reflect market prices in 2014 dollars upon original FDA approval. Source: Memorial Sloan Kettering Cancer Center.

Malin says that in some cases Anthem establishes an out-of-pocket maximum as a safeguard against high co-pays.

Exchange plans that came about as a result of the Affordable Care Act have been found in some cases to exclude key drugs, or place them on the highest cost-sharing tiers, and to have poor disclosure, such that it is difficult or impossible for consumers to compare one plan with another.

 It is another instance of consumers getting a poor deal as payers compete to get and retain business and to avoid expense wherever possible, say advocates and doctors.

Under the ACA you cannot be denied coverage because of a preexisting condition, notes Eric Hargis, CEO of the Colon Cancer Alliance; “However, if a plan puts all the cancer drugs on the highest and virtually unaffordable co-pay, then they are accomplishing the same thing—saying ‘Patients with cancer need not apply.’”

Hargis says this type of abuse of the ACA can often be predicted by the way pathway plans are designed, though he adds that pathways can serve a good end by steering doctors toward sensible treatments that are reasonable in cost and efficacious. “Pathways can help to improve clinical outcomes by making sure that across the board, particularly in an oncology community where you have a doctor who is treating—obviously&mdash;many different forms of cancer, the doctor is completely up to speed on the most recent advances and treatment.”

Malin says this is exactly what Anthem’s pathways program accomplishes. She cites a total of 64 different regimens for lung cancer that meet National Comprehensive Cancer Network (NCCN) guidelines. Those regimens range from $450 to $65,000 for three months of therapy, “with really no difference in outcomes.” Anthem took 8 of those 64 regimens and created a pathway with costs ranging from $450 to $34,000 for three months. “There is still a wide range in order to accommodate patient preferences and if a physician feels that one option might be better for one patient than another, but on average it is much more cost-effective than using the whole range of therapies, including those that are very expensive with no real difference in toxicity or efficacy.”

Physicians are not forced to abandon their preferences for treatment if they are not included in the pathway, Malin says. Coverage payments simply won’t be as favorable. “Generally speaking, the community believes that it is probably appropriate to be on a pathway around 85% of the time, so we are not restricting use of any of those regimens.”

Pathway plans and the advent of guidelines from NCCN and ASCO have resulted in a huge reduction in variations of care that did not make perfect clinical or economic sense, says Malin, but she notes that even now there is still a huge variation in physician choices that leads to differences in quality of care and cost.

Such plans do cut down on waste in cancer treatment, though some professionals interviewed for this article described cancer treatment as inherently wasteful because there are always patients who do not respond to care. “With genomics-targeted testing, there is a lot of effort required to try to identify people who will respond. It’s one of the major areas for improving the efficiency for how to prescribe things, but it has not been realized yet,” says Ramsey.

Coverage changes are not the only method by which payers are pushing back against rising costs, says Mike Neuss, MD, chief medical officer for the Vanderbilt-Ingram Cancer Center. He contends that the often frustratingly difficult approvals processes almost seems designed to make all but the most determined of physicians give up short of the goal of obtaining the optimal approvals for the patients in their charge.

“I think the payers put a variety of impediments in the way to see if you’re really committed to doing or prescribing something,” he says. “And I think they do that through the pre-certification or clinical guidelines process. They’ll inconvenience you ridiculously by it.” Some doctors will put up with being placed on hold for a long period of time. It sometimes takes more than that to get an approval, though. Knowledge and influence also count, says Neuss.

When giving out approvals for the newer class of immunotherapy drugs, payers are often less flexible about coverage, says Neuss. “I think the more expensive the intervention, the more ‘proper’ they are in following the indication. And these are expensive treatments, so I believe the payers will make sure that they’re used according to FDA indication and not according to physician or patient whim.”

Ramsey thinks manufacturer pricing is part of the problem. “Taking [the payers’] perspective, they’re seeing their spend for oncology related care expand rapidly as the cost of new drugs and drug combinations goes through the roof, and they’re under extraordinary pressure to keep the premium costs down, so they’re in a difficult situation right now.”

The way Malin sees it, the frustrations of the prior authorizations process are largely due to the wide variety of plans available in the marketplace, which means that physicians have to work through different platforms and adhere to different requirements in order to obtain the treatment approvals they believe are most suitable. “Trying to keep up with what the different processes are for all of them can be a challenge,” she says. The Cancer Care Quality Program has a Web portal that can be used to access approvals data, which she says has gotten good reviews from oncology practices. Sometimes it will take a third of a day to get an approval; sometimes it will happen within a few minutes, “if practices are able to enter the information directly into the Web portal and don’t have any questions about what information is required.”

Nevertheless, the rise of financial toxicity as it relates to patients’ inability to pay for care is a sign that the medical coverage system in this country is in a state of crisis, say the medical professionals interviewed for this article.

More and more often, pharmaceutical products are being priced in such a way that the patient has a higher percentage of the healthcare bill, says Hargis. “The number 1 reason people call our organization right now is for financial assistance. There are many programs out there and we provide some grants, but—let’s be honest&mdash;cost is still one of the greatest barriers for patients today.”

The alliance is currently backing legislation that would require Medicare coverage of polyp removals that follow from preventative colon cancer screenings allowed under ACA. “We’ve actually had calls from patients saying, ‘I told my doctor if they do a colonoscopy, not to remove the polyp, because I can’t afford it,’” Hargis says.

Ramsey believes advocacy groups in general are going after payers on issues like these but need to direct an equal amount of attention to drug manufacturers, whom he says play a major role in the problem of financial toxicity. “There needs to be pressure on the manufacturers to be more considerate in their pricing.

“Right now, the extraordinary rise in cancer drug pricing is creating a real problem, and patients are the ones who are suffering. Insurers are caught in a web of regulations that really tie their hands about coverage, and as a result pass more cost onto patients. Pharma is taking advantage of market distortions and mandatory coverage laws in their pricing decisions.,” says Ramsey.

Neuss contends that the problem is more universal, and that price should not be a barrier to treatment under any circumstances. “I think we regard healthcare as a free market service, and it’s really more like a utility, like a public utility,” he says. “Just being outraged at the drug price is different from saying, ‘Well, the real problem is something else.’ It’s easy to be outraged. It’s much more difficult to talk about what the real problem is, which is the free market pricing model.”

			Yabroff KR, Lund J, Kepka D, Mariotto A. Economic burden of cancer in the US: estimates, projections and future research. 

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			Cancer Action Network. Cancer drug coverage in health insurance marketplace plans. 2014. http://www.acscan.org/content/wp-content/uploads/2014/03/Marketplace_formularies_whitepaper.pdf. Accessed June 20, 2015.

With the cost of newer immunotherapy drugs soaring into the tens of thousands of dollars per month, payers are under increasing pressure to control spending and are tightening the spigot in various ways, oncology professionals told OncLive in a series of interviews.

Soaring Prices for Oncolytics Prompt Payer Pushback

Physicians have shown they don’t have to be quiet participants in the value argument that is raging in oncologic circles.

There’s little logic in the way manufacturers price their increasingly expensive cancer drugs, the American Society of Clinical Oncology (ASCO) and doctors from Memorial Sloan Kettering demonstrated in June, when they released versions of drug valuation tools that allow users to compare drug prices with drug toxicity and clinical benefit.

ASCO’s framework looks at different drug combinations used in a trial and assigns a net health benefit to the test regimen. The cost of the treatment is not factored into the score, but it is provided for comparison purposes, and it can be very telling.

Looking at a trial of cisplatin and pemetrexed versus cisplatin and gemcitabine (control), ASCO found absolutely no difference in the net health benefit but a wide gap in price: $9193 per month for the test combination versus $811 for the control.

The methodology is still very much a prototype that needs to be augmented by a massive infusion of data, ASCO warned. Still, it’s a glimpse at how useful such an evaluation tool can be for physicians and patients trying to make sound health and financial decisions about oncological care.

Doctors at MSK were less conservative in their approach. Their DrugAbacus tool allows users to assign a dollar value to a year of life and then calculate a fair market price for a particular drug. That value, in turn, can be compared with the actual price of the drug.

Put to the DrugAbacus test, many oncology drugs appear quite reasonably priced, though others seem clearly over the top.

Peter Bach, director of the MSKCC Center for Health Policy and Outcomes, has stated that the rising financial stress on cancer patients was a chief reason behind the decision to develop the DrugAbacus, which he said demonstrates that it’s hard to spot the justification for the high prices of some oncology drugs. While weighing in on the value debate, physicians are also attempting to address what they see as inequities imposed by payers.

The American Society of Hematology has announced its backing for legislation introduced in the House and Senate that would ensure that oral oncolytics and self-injectables are made available to patients on terms “no less favorable” than for drugs administered in physicians’ offices. Key to this issue are the percentage co-pays that are compounded by the soaring costs for newer immunotherapy drugs.

Similar issues are discussed this month in a story about rising drug costs and the means payers are using to control spending. “I think the payers put a variety of impediments in the way to see if you’re really committed to doing or prescribing something,” Mike Neuss, MD, chief medical officer for the Vanderbilt-Ingram Cancer Center, told 

Beyond value and payment, this month’s issue addresses the proliferation of narrow networks, otherwise known as provider groupings that are streamlined to achieve better health outcomes and cost savings. Some high-quality cancer centers have found themselves excluded from these networks, seemingly on the basis of their relatively higher costs. This is a disservice to patients who formerly had access to these centers or who would benefit from having access.

There is value in this type of open discussion. The more people talk about the problems with coverage and value, the more—it can be presumed&mdash;will be done to find solutions.

Physicians have shown they don't have to be quiet participants in the value argument that is raging in oncologic circles.

Value Debate Turns to Drug Pricing

Whether you call them narrow, tiered, or high-performance networks, insurance plans that limit which doctors have in-network status have become a mainstay of healthcare, helping keep costs down but stoking concerns and complaints from hospital administrators and regulators about patients’ access to care.

On the federal and state healthcare exchanges, 45% of insurance networks nationwide fall into the “narrow” category, according to a recent McKinsey study.

 That includes the 17% that are considered ultra-narrow, meaning they cover 30% or less of area hospitals.

Insurers have been creating narrow-network HMOs and similar offerings for at least 2 decades, but like high deductibles and other cost-containment strategies, they have become more prominent in the last few years. Their relatively low premiums have proved attractive to consumers who are now required by law to buy health insurance and increasingly to employers trying to keep a lid on benefits spending.

Between 2007, when 15% of companies that offered workers health insurance included a so-called “high performance” provider network, and 2013, the figure climbed to 23%, according to the Kaiser Family Foundation.

The plans really are cheaper, at least as far as premiums are concerned: on the exchanges, median premiums this year are 15% to 23% higher for traditional broad network plans than for the equivalent narrow network plans, the McKinsey study found. That’s a bigger difference than in 2014, illustrating their growing appeal. Narrow networks have become a common feature of the less expensive bronze and silver exchange plans.

The study also concluded that there is no “meaningful performance difference” between the broad and narrow networks based on Centers for Medicare & Medicaid Services (CMS) hospital metrics. Yet critics argue that by excluding major hospitals and cancer centers from popular, less expensive plans, insurers are at the very least inconveniencing patients who must travel farther for treatment, and in some cases forcing them to forsake their best options at the risk of being saddled with huge debts for out-of-network care.

“We find often that patients say they selected their insurance based just on the lowest cost at the time. All of a sudden you're diagnosed with cancer and then when you actually research the policy, there's very little coverage, horrible benefits, high co-pays and now, the new scenario is a very limited network,” said Terrie Kothe, vice president of managed care at Roswell Park Cancer Institute in Buffalo, New York.

The cost-cutting focus of narrow networks is particularly blind to the need for high-cost care for rare and complicated conditions treated at cancer centers and other specialty providers, critics say.

Roswell Park initially found itself excluded from 2 of the 7 exchange plans in its region and 11 of 16 statewide, the Associated Press reported last year.

 Since then the institute has seen some cancer patients opt to get treated elsewhere, only to receive inadequate treatment and subsequently return to Roswell Park sicker and in need of more intensive care, hospital executives said.

“After they make a decision not to be seen here because of co-pays or out-of-pocket payments, they go into the community, they get the care, and then in some instances they end up back here and we are working to manage their complications,” said chief of clinical services Victor Filadora, MD, MBA. “As you can imagine, the cost of care due to complications is high.”

“For a patient who tries to come to Roswell and is unable to, that can be devastating to them personally as well as financially and medically; that's our major concern,” Kothe said. “We're an entity that was set up to treat cancer and be available to everyone in the community, across the state or across the country. By virtue of these new narrow networks, there seems to be a new restriction on that. It's not fair to those people.”

Roswell Park is among a number of leading cancer centers that found themselves out of network for many local patients when the first exchange plans were released late in 2013, apparently because insurers considered them too expensive. MD Anderson Cancer Center said it was in less than half of the plans in the Houston area, and Memorial Sloan Kettering was included by just 2 of 9 insurers in New York City, according to the Associated Press.

Of 19 nationally recognized comprehensive cancer centers surveyed, only 4 said they were in all the insurance networks on their state exchange.

The situation may have improved slightly since then. In a more recent survey of 20 National Cancer Institute—designated centers in 19 states, all but 1 said they were in as many or more exchange plans as last year.

 Still, the survey by Avalere Health and the National Comprehensive Cancer Network (NCCN) found that a quarter of the centers said they were excluded from most networks in their state exchanges, and just 13% were covered by all the plans.

In states with tiered networks, a variation of a narrow network in which a patient’s out-of-pocket costs vary according the provider’s tier, most of the centers were stuck in tiers 2 or 3, resulting in greater expense for patients. Thirty percent of centers actually rejected offers to be included in certain plans because the reimbursement rates were too low, said NCCN CEO Robert Carlson, MD.

“Some of the centers stated they believed that they actually had been offered contracts with rates that were so low that the carrier knew that they would not agree,” he said. “It was really a lowball offer so they would not have to cover the NCI-designated cancer center.”

Exclusions from narrow networks have led to lawsuits and calls for regulatory reforms. In October 2013, Seattle Children’s Hospital sued Washington’s state insurance commissioner when it learned it was not in-network for 5 of the 7 plans in its county. A month after the exchanges opened, the hospital said it had already treated 125 children whose families had lost contracted access to Seattle Children’s.

“This is a dire situation for our patients,” senior vice president Sandy Melzer, MD, said at the time. “We can’t continue providing services to these patients without reimbursement from their insurance companies. Eventually, these patients will have to seek care elsewhere, and for the treatment of many conditions, there is nowhere else to go in the region.”

Two of the companies soon agreed to include the hospital in its plans, while 2 others gave in shortly before the trial was to begin, Melzer said in a recent interview. The state insurance commissioner also approved new rules on network adequacy designed to ensure that enough providers are in-network near the areas where plan members live.

“When you have a situation where very highly specialized services are offered, you have to be very careful that the unintended consequence of narrow networks doesn't happen, which is that basically people can't get the care that they need, care that's only available at a specialized facility, be it cancer or pediatrics,” Melzer said. “That's what people really have to guard against.”

As insurers started excluding providers, some were accused of not telling the truth about their networks. In California, 2 insurers were accused of a bait-and-switch in which they listed out-of-network doctors as being in-network, leaving consumers with newly purchased policies in the lurch. The group Consumer Watchdog filed class-action lawsuits against 3 insurers, and state investigators alleged that Anthem Blue Cross of California and Blue Shield of California had violated state law by listing doctors in online directories who were not actually in their networks.

The Affordable Care Act attempts to head off the problem of insurance networks with insufficient numbers or types of providers through its list of essential health benefits (EHBs). Among other requirements, the Act states that insurers must cover mental health and substance abuse services and include providers who predominantly serve low-income patients.

A number of states also have their own rules on the proximity of members to doctors, appointment wait times, patient-doctor ratios, and office hours. After the complaints in Washington state, standards for all those factors were made more detailed; for example, 80% of plan enrollees must have providers within a set distance, which varies according to the type of provider and whether the area is rural or urban.

 The state also began requiring monthly updating of provider directories.

The implicit and sometimes explicit criticism of cancer centers’ high costs that has accompanied the battle over narrow networks has left them defending the expensive comprehensive services they provide, including treatment of rare cancers, clinical trials, psychosocial support, and charity care. Carlson, for example, cited a 2014 study that found higher survival rates among patients treated at NCI-designated cancer centers.

“If you then exclude people for whatever reason from accessing a major cancer center, it may be you're disadvantaging them in terms of their likelihood of surviving their disease,” he said.

Implicit in such arguments is the suggestion that the group oncology practices that narrow networks more frequently do include do not provide treatment that is sufficiently specialized or high-quality. Community oncologists naturally reject that claim, saying they are highly effective at relatively low cost.

“You're going to see more narrow networks, you're going to see more tiering come down the road, and in an odd way, that actually may end up benefitting community cancer clinics,” said Ted Okon, executive director of the Community Oncology Alliance.

Contrary to the view of the cancer center representatives, Okon said narrow networks could be “good and bad” in that they restrict patient options but can steer patients toward more efficient providers. But he admitted that those networks, along with high deductibles and other cost-saving features of cheaper plans, could become a bigger issue as demand for oncology care grows in the aging population.

“Under-insurance is a huge problem that is rearing its ugly head already, and I think will even more so as we go on further with the growth of the exchange plans, especially if the growth keeps on occurring in those low-premium plans like the bronze and silver,” he said.

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Insurance plans that limit which doctors have in-network status have become a mainstay of healthcare, helping keep costs down but stoking concerns and complaints from hospital administrators and regulators about patients' access to care.


Narrow Networks: Great Cancer Centers Need Not Apply

At Edward Cancer Center in the affluent Chicago suburbs, patients generally have good insurance, donors have contributed millions of dollars to capital campaigns, and sophisticated services like multi-disciplinary care coordination and patient navigators are supported by the center’s parent hospital.

Yet despite its healthy finances, Edward is eagerly hoping to be selected to participate in the Centers for Medicare & Medicaid Services’ new Oncology Care Model (OCM), a pilot program that will require the cancer center to measurably cut costs even as it beefs up its services and analytical capabilities.

“We've always worked in a situation where our only concern has been the care of the patient, which is fine. That's the way it should be,” said Alexander Hantel, MD, the center’s director of medical oncology. “But at the same time we also are realizing as physicians that the value of what we prescribe for patients has to be more carefully assessed.”

The push for greater efficiency comes at a time of growth for the center, which was established a decade ago when Edward Hospital in Naperville, Illinois brought its visiting oncologists onto its staff. A second site opened nearby in Plainfield in 2009. From 2005, when the center treated 1135 cases, volume at the two sites grew to 1386 in 2011 and to 1850 last year, said administrative director Jenna VanGilder.

The center has 7 medical oncologists, 4 radiation oncologists, 2 surgical oncologists and 7 advanced practice nurses. A third surgical oncologist is coming on in August.

Hantel said he wants to join the Oncology Care Model to address the ever-increasing cost of cancer drugs, or at least to help CMS assess the merits of a new approach. VanGilder said participating would give Edward the jump on cost-containment mandates that all oncology practices could be forced to adopt a few years from now.

“There's obviously some scary things about the model that we know that we don't do that great, but we also realize that we probably should. So why not learn along the way and figure it out now, rather than wait?” she said.

Despite its money-saving potential, the Oncology Care Model has taken some criticism for preserving traditional fee-for-service (FFS), tying incentive payments to factors the oncologist does not control, and for paying according to “arbitrary” 6-month treatment episodes.1 ASCO’s preferred alternative, called Consolidated Payments for Oncology, would depart from FFS by switching to relatively large payments at the start of treatment and every month, as well as payments during treatment holidays and after treatment ends.2 Pay would be cut for practices that don’t follow guidelines for prevention of complications, end-of-life care, and use of drugs, testing and imaging.

Edward, however, has embraced the OCM. In addition to moving to the edge of payment reform, Edward would benefit from the model’s $160 monthly per-patient fee, which is intended to cover coordinated care and other improvements in treatment of chemotherapy patients, VanGilder said.

“We offer a lot of these things already, and we're not getting the extra per-beneficiary payment per month. We do provide a lot of that care coordination,” she said. “Not that we're going to make money by any means, but to get some reimbursement to assist with these resources would be nice.”

The care coordination comes via specialized clinics for lung, brain, breast, gastrointestinal and genitourinary cancer. The lung clinic, for example, has a dedicated surgeon, medical oncologist, radiation oncologist, pathologist, radiologist, and psychosocial and research staffers, VanGilder said. The physicians meet weekly to discuss cases and plan treatment, and an advanced practice nurse arranges appointments and shepherds the patient through.

The cancer center and Edward Hospital have also been on the forefront of meeting quality standards of the type required by the Oncology Care Model, Hantel said. They include ASCO’s Quality Oncology Practice Initiative Certification.

“We're probably a relatively high cost practice just because we are in a high-reimbursement and high-utilization region of the country. But at the same time, we have always done all of the quality improvement measures,” he said. “We're way ahead of the curve in terms of really trying to give good quality care and do it in a measurable way in our practice. So we have every certification you could think of.”

Hantel said his only major concern about the OCM relates to the long-term sustainability of the model’s incentive scheme.

“In the short term there's no real downside for us to participate. It's a carrot and stick approach. The carrot is coming out right now,” he said. “The question is, what's the stick going to be down the road? And how many percentage points are we going to be asked to ratchet things down every year beyond that point? If you're really, really efficient, it's going to be hard for you to ratchet things down after a while. That's the problem.”

“If you become accustomed to the revenue from the program and then you don't get it all of a sudden, that's a bigger hit,” he said.

The OCM has attracted significant interest so far. About 450 practices have submitted letters of intent, though some may back out once more details of the model are released. CMS has suggested it will enroll about 100. There are four selection criteria, worth up to 100 points: 40 for implementation plan, 25 for financial plan, 30 for payer participation and 5 for patient diversity.

The criteria pose some hurdles for Edward. The center may not score well for diversity, VanGilder said, and it has so far not confirmed that any of its insurers will agree to set up their own payment arrangements similar to the OCM, which could hobble its application. She said the center is in discussions with its second biggest payer, Blue Cross and Blue Shield of Illinois, and is hopeful that the company will sign on.

If Edward is selected, it will face a set of complex administrative challenges as it works to meet the OCM’s goals. One is survivorship, which is basically care coordination after treatment ends and patients stop coming to the cancer center. Such efforts ensure patients get recommended follow-up care to minimize recurrence of disease while avoiding duplicative testing, and should ultimately reduce unnecessary costs.

“Survivorship is just a huge ball of wax, and we haven't quite gotten that all together yet,” VanGilder said. “You should give be able to give patients a printout of everything that's happened to them and recommendations for follow-up care and health promotion activities. That can be very cumbersome, because no electronic record is pulling in all that information like you would want it to. You have to spend 2 hours filling out a form for a patient.”

“And it's difficult to catch patients at the point of survivorship, too. Every cancer patient is unique. Some get chemo and they're done; those might be easier to catch, so you can make sure they get their survivorship care plan. But then maybe others end up going to radiation, or then they go to surgery. How do we make sure we can catch them at those points? Those are things we struggle with,” she said.

Among other requirements, OCM practices will have to start providing new patients with accurate upfront estimates of their out-of-pocket costs before treatment begins. That requires understanding the vagaries of every patient’s insurance plan. And even though Edward has lately expanded its palliative care program, as part of OCM it would probably also have to allocate more staff time to discussing end-of-life issues with patients, VanGilder said.

The biggest unknown stems from the Oncology Care Model’s shared savings component. CMS will set benchmarks for the cost of chemotherapy episodes and make incentive payments to practices that come in at 4 percent below the target. Practices that don’t meet benchmarks and performance measures could be booted from the program. Yet the target prices have not yet been announced, making planning tricky.

At the same time, Edward’s relatively high cost structure suggests it does have opportunities to become more efficient and spend less regardless of the targets.

Some of that will involve counseling savvy, well-insured patients not to demand care that may not be necessary, such as after-hours emergency room visits or imaging for unexpected pain, VanGilder said. Data analysis suggests that Edward’s staff need to initiate discussions about hospice care sooner, which can be particularly difficult with the center’s large cohort of younger breast cancer patients, she said.

“Are you giving chemotherapy in the last week of somebody's life? Is that the best practice? We don't do very well on that measure,” VanGilder said. “That's why we probably need more advanced care planning and more frank discussions with patients.”

For now, Edward is focused on the success of its application, which was due June 30. CMS will notify applicants of their status around the end of year. If the center is not selected it may pursue an OCM-like strategy anyway, VanGilder said, because oncology is inexorably moving in the direction of better understanding and tighter control of the costs of care.

“Quite honestly, if we aren’t chosen we're really hoping maybe another payer will be interested in doing it with us, or we will try to look at this model and implement things on our own, knowing that this is going to happen,” she said. “Do we really understand the cost to care for cancer patients? We haven’t figured out a great way to give patients an estimate of total costs and out of pocket costs. The model is making us really think about that.”

			Polite BN, Miller HD. Medicare innovation center Oncology Care Model: a toe in the water when a plunge is needed. 

. 2015;11(2):117-119. http://jop.ascopubs.org/content/11/2/117.full. Accessed June 14, 2015.

			American Society of Clinical Oncology. Patient-Centered Oncology Payment: payment reform to support higher quality, more affordable cancer care (PCOP). http://www.asco.org/advocacy/asco-releases-payment-reform-proposal-support-higher-quality-more-affordable-cancer-care. Published May 21, 2015. Accessed June 14, 2015.

Edward Cancer Center is eagerly hoping to be selected to participate in the Centers for Medicare & Medicaid Services' new Oncology Care Model, a pilot program that will require the cancer center to measurably cut costs even as it beefs up its services and analytical capabilities. 

Illinois Cancer Center Looks to Get Ahead of the Value Curve

Online forums have peeled away some of the barriers to understanding her patients, says Deanna Attai, MD, a well-known clinical professor of surgery at the David Geffen School of Medicine at the University of California Los Angeles. Attai is co-moderator of the Breast Cancer Social Media (BCSM) Twitter community, a regular Monday open forum.

“When you see two women in the middle of the night having a real raw conversation about their chemotherapy side effects, it is very different from what you see in the office,” says Attai.

Social media — which broadly defined encompasses many different forms of Web-based exchange – has the potential to make a deep imprint on oncology practice, but many clinicians are still reluctant to participate, physicians interviewed by 

In some instances the reasons for holding back are a lack of time and skepticism that an investment in posting online will advance their practices in any material way or contribute much toward patient welfare, says Don Dizon, MD, an oncologist at Massachusetts General Hospital and chair of the Social Media Working Group for ASCO, which is tasked with evaluating and guiding social media participation within the society and for its members.

Many use social media to further their professional education and stay current, but a huge concern among physicians is the danger of compromising their reputations as community professionals and potentially violating patient privacy rights. For example, Attai noted that an innocent post could lead to a harsh response from a special interest group. “That’s not something we expect as physicians, and we don’t really know how to deal with it,” she says.

Nevertheless, many practices from the administrative end have embraced the potential of social media and are encouraging their physicians to participate. “There’s a heavy investment in a social media presence at the institution level,” says Dizon. “It’s all about exposure and making sure that name recognition is increased in a comparatively more competitive environment for patient attention.”

These institutions all have the same problem, though. “Every single one of them, I believe, is struggling with how to get buy-in from their providers,” says Dizon. “What’s happening [online] isn’t necessarily reflected at the physician level in any of those institutions or health practices. You cannot force someone to join Twitter or Facebook or write a blog, and you certainly can’t post in someone’s name, because that would be unethical.”

Academics don’t receive credit for tweeting, and they may feel that writing a grant application is a far better use of time, Dizon says. Physicians, meanwhile, may be pulled in many directions by their workplace obligations. They may have to see inpatients or do administrative shifts in a hospital. “It’s all about work-life balance. If you’re doing so much at work already, how much time do you have to devote to something else?” he asks.

This situation is frustrating for administrators, who feel that participating in social media is important for establishing a practice in the community and for building brand. “One of the questions I am always fielding is, ‘How do we get our people to tweet?’ And I don’t think anyone at the institutional level or at the marketing level of any one institution or practice has the answer for that,” says Dizon.

Attai is in the camp of social media converts who believe that patient confidentiality can be respected with proper training and that, although physicians are busy, social media is something they can do if they are dedicated. “As with anything, you have to figure out how involved you want to be, how important it is to you, and then figure out how to manage your time. It took me a little while to learn,” she says.

Recognizing the growing influence of social media in oncology, ASCO put out a set of guidelines for physicians in 2012.1 Dizon was the lead author. The report noted the inherent risks of publishing material online, while praising the value of disseminating good quality medical information that would serve as a useful resource to doctors, patients, and others. Although physicians use social media in different ways, the report said, giving patient advice directly over the Web is least often done, and the authors expressed doubt that that it can be done in a manner that satisfies patient privacy and regulatory requirements.

Talking about the ways that social media has changed her practice, Attai says it has exposed her to a world of patient experience that was not available to her by seeing patients for 15 minute appointments only. That, in turn, has made her a better, more empathetic doctor. “It’s changed the way I listen. It’s changed the way I ask questions,” she says. However, she said her patient interaction online has not significantly improved her practice revenues, nor did she expect it to.

Dizon agrees that for him, too, the information exchange via social media has been paramount in terms of value. “You’re getting voices not only from the folks you agree with professionally, you’re getting the patient voice and the advocate voice. You’re getting a 360-degree view of any one topic, so that is, for providers, the benefit of social media. Whether or not that is enough remains to be seen.”

Social media may not have made a huge difference in the amount of patient traffic that walks in through Attai’s doors at UCLA Health Burbank Breast Care, but some patients do seek her out, having heard about her through Twitter or other online forums. Attai takes that as a sign of how much better informed patients are today, and how much research they are doing independently to learn about their disease and about available treatment. This in turn has made physicians much more careful about reputation, their online image, and their so-called bedside manner, says Attai.

The old stereotype of a paternal physician who always knows what’s best for the patient is not entirely a fiction. Those doctors still do exist, but the internet and the social media revolution have turned them into an endangered species, says Attai. “One of the things that comes up a lot on BCSM is ‘How do I get a second opinion?’ ‘How do I ask?’ ‘I’m afraid that I’ll hurt the doctor’s feelings.’ You’ll have all the patients as well as the doctors rushing in, saying ‘This isn’t about you. This isn’t about the doctor’s feelings.’” Attai recalls having had a few of those doctors when she was younger and feeling somewhat intimidated before she decided to go elsewhere for treatment. “Patients are taking ownership, and I think that is good, because they are with their problem 24/7. It is up to them to find a set of care providers they can work with and develop a relationship with,” she said.

These Web-empowered patients increase the pressure on physicians to make themselves known over social media, Attai notes. “I think more and more it’s going to become essential that physicians have something. It doesn’t mean you have to do a website. It doesn’t mean you have to go on Twitter or Facebook, but putting out some sort of your own content that links back to you as a physician, I think, is going to be more and more important going forward.”

ASCO has been involved on Twitter and Facebook with online populations of its members and with the general public, and those efforts have been highly successful, particularly online tumor board platforms, which are designed for clinicians though anybody who reads the site can offer input, says Dizon.

“It was in the context of having all of these social media channels that the questions came up: Are we using them effectively, and are the messages coming from ASCO consistent, and also, can we utilize these better, and then finally, can we encourage our membership in a more thoughtful way to engage in these platforms?” says Dizon. “Because, the God’s honest truth is, while there will be people who are engaged in social media, it is the minority of folks who are currently in clinical practice."

Another problem with trying to promote the use of social media in oncology is that some forums essentially fly above the radar of those they are intended to reach. “A lot of what happens on Twitter stays on Twitter,” says Dizon. “I sometimes feel that those of us who believe in the power of social media and believe in the power of patient engagement are speaking only to one another, isolated in an echo chamber, and I’m left wondering whether or not we’re really influencing the larger conversation of change.”

This is a perception that ASCO is trying to explore and understand better in its attempt to develop a plan to expand the use of social media among oncologists, Dizon says. “We’re sending a very large signal to oncology, but also beyond oncology, to medicine in general, that we believe this is not a space that we should ignore.”

In five years’ time things will be very different, Dizon believes. He thinks part of the slowness of adoption in oncology is a generational issue where doctors who grew up with pens and yellow pads are still using those by force of habit, whereas some newer doctors are “designing their own apps.”

“We’re now going to come to the era where you’re looking at wearables and data coming from all over the place,” says Dizon. “I think in the era of big data, the social media space will become a part of regular practice. It’s all a part of the tech revolution in medicine that is happening now. I bet it’s going to be a lot harder not to get involved.”

	Dizon D, Graham D, Thompson MA, Johnson LJ, Johnston C, Fisch MJ, et al. Practical guidance: the use of social media in oncology practice. 

. 2012;8(5):e114-e124. http://jop.ascopubs.org/content/8/5/e114.full. Accessed June 10, 2015.

Social media â€“ which broadly defined encompasses many different forms of Web-based exchange â€“ has the potential to make a deep imprint on oncology practice, but many clinicians are still reluctant to participate.

July 2015 | Oncology Business News®

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Illinois Cancer Center Looks to Get Ahead of the Value Curve

Doctors Wary of Social Media Exposure But See Value in Dialogue