Permanent SGR Fix Falters, ASCO Issues Cancer Report

Clifford A. Hudis, MD

Despite repeated attempts to pass a permanent fix to address Medicare’s sustainable growth rate (SGR) formula, efforts by lawmakers on both sides of the aisle have stalled again. So, it looks like another temporary patch will have to do.

The Senate passed the bill by a bipartisan 64 to 35 vote on March 31, which now heads to the president’s desk. The bill includes language to fix the SGR for 12 months and delay ICD-10 implementation.

Industry stakeholders would have much preferred a permanent fix to the SGR formula, but most are in favor of a stopgap measure to prevent a 24% drop in Medicare reimbursement rates from going into effect on April 1.

The bill, HR 4302, calls for a 0.5% update through December 31, 2014, and a 0% update from January 1, 2015 through March 31, 2015. In addition, it includes a provision to delay the transition to ICD-10, which would prohibit the Department of Health and Human Services from implementing the transition at any point before October 1, 2015.

Landmark Report Released

This legislative drama is playing out even as the US cancer care system is faced with the prospect of a dramatic increase in the number of patients with cancer, and proportionately fewer oncology specialists to treat them, the American Society of Clinical Oncology (ASCO) warned in a webcast on March 11.

During the webcast, led by ASCO President Clifford A. Hudis, MD, the group called for Congress to help stabilize payments to doctors under Medicare by repealing the SGR. The webcast also highlighted a landmark report released by ASCO, The State of Cancer Care in America: 2014.

The State of Cancer Care in America: 2014 highlights how oncologists are trying to adapt to a growing demand for services, changes in healthcare delivery systems, and to the economic pressures that small oncology practices face. Specifically, the ASCO report addresses the challenges faced by a shrinking oncologist workforce, the viability of the small and mid-sized practices in rural areas of the country, and quality and value initiatives to implement moving forward.

Viability of Small and Mid-sized Practices

As a result of payment cuts and lowered reimbursement for chemotherapy agents, ASCO says smaller practices, which consist of 1 to 2 physicians, are becoming increasingly rare. As the primary source of cancer care in small towns and rural communities in the South and West, this trend will make access to local high-quality, personalized treatment burdensome to patients.

In 2013, the ASCO National Oncology Census noted shifts in the characteristics of oncology practices, notably changes in practice size, the number of affiliations between practices and other entities, and a wider array of physician specialties housed within each practice. The census was fielded in 2012.

The census data suggest that oncology practices as a whole are growing larger and that smaller practices (consisting of 1 to 2 physicians) are becoming increasingly rare (see Figure 1).

What’s fueling the decline in the number of small and mid-sized practices are recent cuts to Medicare physician payments and other factors. These practices, concentrated in the South and West, serve more than one-third of new patients, according to ASCO’s research.

ASCO is concerned because these smaller practices are often the primary providers of cancer care, enabling people to receive high-quality, personalized treatment that’s close to home.

Figure 1. Size of Practice as a Proportion of Total Respondents

Source: American Society of Clinical Oncology. The State of Cancer Care in America: 2014. Reprinted with permission

Carolyn B. Hendricks, MD, a solo practice medical oncologist in suburban Maryland said during the ASCO webcast that, for the first time, she couldn’t afford to treat her patients in her office but had to send them to the hospital to receive their infusion therapy. “My patients were very surprised to see the out-of-pocket costs associated with receiving treatment in a hospital,” she said during the webcast.

Her practice faces a daunting future because of the increased cost of chemotherapy drugs and the lowered reimbursement paid by the Centers for Medicare & Medicaid Services, a practice sometimes referred to as “buy-and-bill.”

“Giving chemotherapy is expensive,” she said. “My practice has lost revenue and has to purchase chemotherapy on credit and then scramble to be reimbursed adequately.”

Years ago, the buy-and-bill model was lucrative. That’s quickly changing as higher priced drugs and lower reimbursement affect the viability of small practices, leaving them with 4 possibilities: purchasing another practice, selling the current practice, merging with a larger practice or hospital, or closing the practice entirely.

Workforce Shortages

If more small practices close, it will have an effect on workforce shortages, says the report.

ASCO estimates that by 2025, the demand for oncology services will grow by 42% or more, while the supply of oncologists will grow by only 28%. That translates to a shortage of more than 1480 oncologists by 2025.

Like most clinical care workforces, medical oncologists are growing older as a group. In 2008, the proportion of oncologists aged 64 years and older surpassed the proportion under 40 years of age, according to the report.

That age gap is expected to grow wider, the report said, since medical oncologists tend to be slightly older than the general physician population.

The American Medical Association (AMA) identifies about 13,400 physicians in the United States who specialize in adult medical oncology and/or hematology. Separately, Medicare’s Physician Compare database identifies 11,300 medical oncologists and hematologists/ oncologists who treat Medicare-eligible patients (see Table). The report does highlight an encouraging finding: subspecialty growth in overall numbers appears to be driven primarily by increases in the hematology/oncology and medical oncology workforce (see Figure 2). However, the number of gynecologic, pediatric, and radiation oncologist subspecialists is relatively flat.

Table. Numbers of Physicians in Oncology Specialties

Oncology Specialty

Masterfile Number

Physician Compare Number (Medicare)

Medical Oncology and/or Hematology

13,409

11,343

Gynecologic Oncology

506

921

Radiation Oncology

4581

4178

Pediatric Hematology/ Oncology

2188

Not relevant

Surgical Oncology

443

760

Source: American Society of Clinical Oncology. The State of Cancer Care in America: 2014. Reprinted with permission.

Such pressures on the oncology workforce could not come at worse time, however. Although advances in treatment and screening have produced a decline in cancer deaths in recent decades—with 13.7 million survivors in the United States—the number of newly diagnosed cases of cancer is projected to increase by as much as 42% by 2025.

Quality and Value of Cancer Care

To improve the quality and value of cancer care, and somewhat lessen the impact of workforce shortages, ASCO data show that practices appear to be increasing their use of advanced practice nurses and other nonphysician providers.

In addition, ASCO and many practices are exploring new payment and delivery models that reward high-quality care, reduce administrative burden, and pay practices better for the services needed by patients with cancer.

ASCO is recommending the development and testing of new care delivery models and payment models, ending persistent financial threats, and repeal of the SGR. The group also recommends greater use of physician-led quality initiatives such as ASCO’s Quality Oncology Practice Initiatives (QOPI) and the CancerLinQ learning system that is currently under development and will provide oncologists, regardless of geographic location, personalized guidance and real-time quality feedback to improve patient care.

Offered as a free program to ASCO members, QOPI is an oncologist-led, practice-based quality assessment and improvement program.

Figure 2. Numbers of Oncologists (MDs and DOs)

Source: AMA Masterfile and The American Society of Clinical Oncologists. The State of Cancer in America: 2014. Reprinted with permission.

The program integrates measures developed by practicing oncologists and quality experts, and spans the continuum of cancer care. The measures, which are reviewed and updated annually, are based on clinical guidelines, published studies, and collective expert consensus— ensuring that emerging science and new clinical recommendations are considered by participating practices without a significant research-to-practice delay.

The ASCO CancerLinQ initiative is focused on building a “learning health system” composed of a knowledge-generating computer network that will collect and analyze cancer care data from millions of patient visits and expert guidelines— and feed that knowledge back to providers at the point of care. In this way, CancerLinQ will support greater consistency and quality in practice—and speed progress in developing new or better treatments.

The CancerLinQ prototype featured the following core functions:

• Acceptance of any cancer care data, in any format, directly from electronic health records and other sources, overcoming the long-standing hurdle posed by inconsistent health data standards.
• Generation of individualized guidance on the care of any given patient with breast cancer based on automated, machine-readable versions of ASCO expert breast cancer guidelines. The full CancerLinQ system, when implemented, will also provide guidance based on the collective experiences of other similar patients.
• Access to and exploration of a database of information on the care of patients with breast cancer—including patient characteristics, treatments, and outcomes—to identify real-world trends and associations and new hypotheses for research.
• Feedback on physicians’ performance against quality measures from QOPI.

“The US cancer system is among the best in the world, but it cannot continue to meet the growing needs of patients unless fundamental, systematic change is pursued,” Hudis said at the conclusion of the webcast.