Future Trends in Cancer Care 2011-2021

by Don Jewler, Director of Communications, ACCC

The ride may get bumpy, says Becca Booi, PhD, in her recent Oncology Issues forecast about cancer care over the next decade. I urge you to read her prognostication and suggestions as to how cancer programs can best take advantage of growth opportunities.

“Multiple forces are exerting pressure on oncology care delivery,” Booi says. Payment and policy decisions, such as healthcare reform, promise to expand the number of insured patients and improve access to care, while new technologies are expected to facilitate treatment in the outpatient setting.

And then there are the aging baby boomers.

Taking into account population growth alone, demand for inpatient cancer services would be expected to grow at 21 percent over the next 10 years, says Booi. However, taking into account additional factors, she forecasts more moderate inpatient cancer services growth totaling only 7 percent over this time frame. Why? Back to new technologies. Innovation will continue to shift care delivery to the outpatient setting. As an example, she cites early oncology medical home models, which bring together case management, patient education, and IT capabilities to improve care coordination, which in turn may dramatically reduce the number of chemotherapy patients that present at the ED or are admitted to the hospital with chemotherapy-related side effects.

Demand for outpatient cancer services is projected to grow dramatically—a 38 percent increase in outpatient cancer service volumes from 2011-2021, driven in part by increased availability of “previvor” services for high-risk patients (e.g., genetic counseling and testing) and increased use of advanced imaging modalities, such as CT, MRI, and PET in the diagnosis, staging, and monitoring of cancer patients. Two particular areas of strong projected growth over the next ten years are stereotactic body radiation therapy and interventional oncology, such as radiofrequency ablation (RFA), cyroablation, and embolization, which offer strong growth opportunities with both clinical and programmatic benefits.

So, how can cancer programs best navigate the ride and capture future demand?

Foremost, says Booi, combine high-tech and high-touch offerings with seamless, coordinated care across the continuum. Identify the appropriate strategies for your individual market to maximum your community cancer center’s growth potential. And communicate value through marketing and education.

Year in Preview: Oncology Care 2012

by Matt Farber, Director of Provider Economics and Public Policy, ACCC

Now that a tumultuous 2011 is history, let’s look ahead to 2012 and all that the new year may bring to the oncology community. Overall, 2012 shapes up to be exciting–from the sustainable growth rate (SGR) fix (again) to the Supreme Court ruling on the constitutionality of the Affordable Care Act’s individual mandate to the implementation of Accountable Care Organization Rules (ACOs) and state exchanges to the Presidential election.

Here’s my Year in Preview, a glimpse into the future–with apologies to Washington Post writer Dave Barry (“Year in Review 2011″).

January
• A cold wind blows into Washington, D.C., when Congress returns from its winter recess. Just a few things remain on its legislative plate from 2011. First up, we hope, will be the SGR fix. My prediction: much discussion throughout the month, but ultimately, no action until February.
• The first accountable care organizations (ACOs) will start up as part of the CMS Pioneer Demo program. Thirty-two programs from across the country were selected to participate. Programs that would like to sign up for the regular ACO model can do so now with start dates in April and July.
• Cancer program leaders will gather for ACCC’s 7th Annual Hospital Summit. I predict that participants who gather in Orlando will leave with strategies to lead their cancer programs to fiscal fitness and ways to deal with a number of new and revised Commission on Cancer standards, including public reporting, new requirements for quality studies, and new responsibilities for the cancer liaison physician.

February
• Congress is faced with a February 29th deadline to fix the SGR before a 27 percent cut takes effect. My hope is that the extra (leap) day this month will allow legislators to put a deal together. Both parties would like to repeal the SGR, or provide a long-term fix; but cost is the issue. I expect to see another short-term fix. Two years may even be a bit optimistic, with a fix through 2012 more likely.
• I see a new acronym: HOP, the Hospital Outpatient Payment (HOP) Panel, which rises as the Ambulatory Payment Classification (APC) Panel sets. CMS has renamed and expanded the advisory panel to deal with supervision issues in the outpatient department. Since there are never any questions about supervision levels in oncology care, I am sure this will not be an issue ACCC will track.

March
• The federal government argues before the Supreme Court that the individual mandate of the Affordable Care Act is indeed constitutional. The Supreme Court will likely take a few months to release its ruling, but March is sure to make for an exciting time in the healthcare reform arena.
• The community oncology meeting season roars in like a lion. The most important meeting: ACCC’s 38th Annual National Meeting, March 12-14 in Baltimore, Maryland, which explores solutions to the oncology drug shortage crisis, new trends in cancer reimbursement and care , the Commission on Cancer standards, and the range of choices hospitals face in employing physician practices.

April
• Now that the Supreme Court has argued the merits of the Affordable Care Act, Congress renews its own debate on the Act. Despite heated confrontations and with no likely actionable outcomes, the Affordable Care Act moves forward. (ACCC has an overview of the ACA rules and their effect on oncology.)
• Programs that have been approved by CMS as ACOs start reporting benchmarks and attempting to achieve shared savings.
• States across the country continue to develop their exchanges. Much of the key aspects of state exchanges have been left up to the states to decide, such as how they may participate, what must be covered, and what to do with plans across states.
• Tensions in Washington, D.C., calm as Congress takes its recess in observance of the Easter and Passover holidays.

May
• The crystal ball is cloudy, but it’s possible the Supreme Court makes its decision on the Affordable Care Act in late May, but the decision also may not come until June. Many believe that, beyond the policy implications of the ruling, the decision will also have a major impact on the Presidential election in November.
• Legislative action heats up in many states as state legislatures finish their sessions in April and May. Issues affecting cancer care are debated in state capitols across the country, ranging from coverage of mammography to oral parity to the use to off-label therapy to the regulation of pain medication. (By the way, getting involved on the local level can be very important on these issues, as state officials often rely on the stories from their constituents to make decisions.)
• May will also mark the first ACCC Regional Economic and Management meeting for 2012. Check back on the website for location and agenda details.

June
• Excitement builds about new therapies in the oncology community thanks to the American Society of Clinical Oncology Annual Meeting the first weekend in June. As new therapies come on to the market, many questions may remain beyond the clinical utility of a therapy:
1. Will the drug be covered?
2. What is the patient responsibility?
3. Is the drug an oral or an injectable?
4. Will it only be available on a limited distribution network?
5. Will it be included on my hospital formulary if we are a participating ACO?
ACCC continues work to provide answers to these questions, helping to ensure that our members can have access to innovative therapies.
• The second and third ACCC Regional Oncology Economic and Management Meetings of 2012 get underway.

July
• Although the 4th of July brings fun and festivities on the home front, no such joy awaits for healthcare reimbursement policy. Each year, on the day before July 4th (or thereabout) CMS releases its proposed rules for the following years for the Hospital Outpatient Prospective Payment System (HOPPS) and the Physician Fee Schedule (PFS). With Congress on a week break for the holiday, ACCC is busy reading the hundreds of pages of proposed rules for the following year and writing a summary of the rules for members both on the website and in conference calls.
• Hopefully Congress will have passed a long-term fix of the SGR earlier this year, but if not, we may be dealing with 3-6 month fixes that come up every so often as well.
• ACOs approved by CMS can start reporting.

August
• Washington, D.C., is very hot and humid. Smartly, Congress takes a month long recess. However, ACCC is working diligently to draft and submit comments to CMS on the proposed HOPPS and PFS rules.
• Most likely the second meeting of the HOP Panel takes place. Here, ACCC will probably testify on issues in the proposed HOPPS rule that we are concerned with. (Recently, the testimony revolved around the issue of declining reimbursement for drugs and pharmacy overhead services. Despite the increased costs associated with drug shortages and with REMS, or Risk Evaluation and Mitigation Strategies, overhead reimbursement has continually declined, despite efforts of ACCC and other organizations.)

September
• We’re in to the closing stretch of the current Congressional session and the Presidential election of 2012. Congress has a number of bills it must pass in September, as the government’s fiscal year ends September 30th, which means that appropriations, or spending bills, must be approved by the end of the month. If this doesn’t happen, Congress is forced to pass continuing resolutions to keep the government operating for months at a time. Given the uncertainty around the spending bills, FDA PDUFA (Prescription Drug User Fee Act) reauthorization, the SGR fix, the status of the Affordable Care Act, and the possible repeal of the trigger, expect more continuing resolutions from Congress.

October
• October will play host to ACCC’s 29th National Oncology Conference in San Antonio, Texas, from October 3-6th. We will continue to recognize ACCC innovators with our second annual Innovator Award presentations. In 2011, 14 innovators received recognition.
• Watch out. October brings advertisements on TV and radio associated with a political candidate. The election is just a month away and if 2008 and 2010 are any indications, a lot of money is going to be spent on trying to convince voters who to vote for.
• Don’t be spooked if just before Halloween, CMS releases the final 2013 HOPPS and PFS rules. (CMS likes to release major rules right before holidays!)

November
• Finally, the Election arrives on the 2nd Tuesday after the first Monday (or November 6th, if you don’t want to look at a calendar). Okay, now that this event is over, let’s get back to the work at hand.
• ACCC will host a conference call for its members on the final 2013 rules in mid-November.
• The 4th ACCC Regional Oncology Economic and Management Meeting of the year. Locations are yet to be determined, but let us know if you have any suggestions. (My vote is for Hawaii!)
• Congress will be in recess at the end of the month for the Thanksgiving holiday. (I feel like I have said Congress will be in recess pretty often. Here is the official House of Representatives calendar for the year.)

December
• Congress is slated to be in session only for the first two weeks of December. This year as in the past legislators may have to delay their holiday break to deal with “must-pass” legislation such as the SGR (hopefully not), expiring tax breaks, and spending bills. But wait. Congress will be in what is called a “lame duck” session, which means that those Representatives and Senators who have been voted out of office will no longer have a future in Congress to look forward to. This change in status may lead to unpredictable votes, as members reassess their positions on important bills.
• December will also likely see the final two Regional Oncology Economic and Management Meetings of the year for ACCC. We hope to see you at one this year.

A deadline looms. Because the Super Committee failed in its efforts to find $1.2 trillion in cuts in 2011, an automatic trigger will go into effect in January 2013, unless Congress steps in to stop it. Many Congressmen have already stated a desire to do just that, even though the President has stated he would veto any effort to halt the trigger. Without Congressional action, Medicare will face a 2 percent across the board reduction in payments.

The year ends as it began with a cold wind.

Reflections on a Career in Oncology Care

by Alan S. Weinstein, MD, FACP, former ACCC Board of Trustees Member, senior physician advisor, Virtua Fox Chase Cancer Program, Marlton, N.J.

What a difference three decades make.

When I became a board-certified medical oncologist in 1978, there were less than 1,200 medical oncologists in the entire United States. Now there are more than 10,000, according to ASCO! Very few oncologists practiced in community settings then. Most practiced in single- or two-men groups in the suburbs and carried a clinical academic link to an academic center. Note that I stated “men” not “persons,” because I remember only a few dozen women medical oncologists then, and almost all held academic positions.

When I first entered practice in 1979, I joined another established hematologist/medical oncologist as only the third medical oncologist in our entire county. Our team consisted of a RN cancer registrar, a single radiation oncologist running a “cobalt” unit, and two surgeons who cared for most if not all the cancer patients in our 225-bed hospital. We had one RN in the hospital who “specialized” in caring for our patients and two nurses who gave chemotherapy in our office practice. Patients who could not afford to be seen in our office were treated in the hospital Tumor Clinic where they were seen by the surgeon, radiation, and medical oncologists together with the “cancer” nurse and the registrar. The registrar kept the notes as she needed them to complete her registry entries. I remember thinking then that it was an efficient way to see new patients! The communications were so much better than at my academic training center where notes from other docs often showed up two months later and were carbon copies or illegible scrawl.

More than 30 years later, I marvel how we take for granted the almost instantaneous sharing of our records and reports. I smile at the frequent grumbling when access to information is delayed just a few hours or days. I also marvel at our Cancer Committee meetings, where 20-30 representatives of the key parts of our multidisciplinary team often meet to share operational reports, outcomes, and strategic planning of our program.

Most changes have ultimately led to improvements in practice and patterns of care and better outcomes. Some changes, however, have created difficulties and impediments that make daily care and operations more difficult and less rewarding, even if they are necessary. More complex and sophisticated record keeping and patient care do not always translate into better. I cringe over some of the practice patterns I frequently see: a 15-minute office visit becomes 13 minutes of keying in information on a template or check list and 2 minutes in discussion, leaving no time for listening to the patient, let alone a careful examination!

Coordination of cancer programs has become so complex that the parts demand their own priorities and agendas without regard to the whole. We now argue over what is the best way to maximize return on investment, leave support programs and social programs unfunded as they cannot be supported with the dollars available, and cannot see our less fortunate patients because we cannot afford to care for them. Clinics are a thing of the past because hospitals cannot fund them and clinicians cannot donate their time!

That said, I still have hope for the future.

The number of targeted therapies available is growing rapidly, making individualized cancer care based on the genetic signature of a cancer— not whether it came from breast or lung—a real possibility in my lifetime. With genomic research expanding rapidly, I am confident of success.

Eventually our abilities to communicate electronically will bear fruit as well. I am hopeful that systems will be able to communicate better with each other and that patterns of care will become more standardized, leading to better quality and efficiencies of care.

Lastly, I am hopeful that our programs will become better integrated, so our “parts” will become one. Multidisciplinary programs are a necessity in our very complex specialty, and coordination of care means efficient care. As our hospitals and health systems learn that coordinated, quality care is the best return on investment, outcomes will improve.

As a recently retired practicing community medical oncologist and a retired medical director of a very successful community cancer center, I’ve seen many changes since the late 1970s. Overall, my career has been exciting and rewarding. I’ve been privileged to witness the growth and sophistication of community oncology as it has evolved to serve many communities–urban and suburban, rural and minority, affluent and disenfranchised.

We still have a long way to go, but we have made great strides our ability to deliver excellent community oncology care to all our citizens. Although I might be on the sidelines, I look forward to even greater changes and improvements in the next several decades.

The Doc Fix: Victim of a Congressional Train Wreck

by Sydney Abbot, JD, Policy Coordinator, ACCC

UPDATE. Just before Christmas, Congressional leaders agreed to vote on, and subsequently pass a two-month sustainable growth rate (SGR) fix, along with the two-month extension of the payroll tax credit. The vote will extend the current conversion factor through the end of February 2012.

Here’s what happened leading up to the short-term fix:

In the hope of passing a “doc fix” more quickly, Congress decoupled the sustainable growth rate (SGR) temporary fix from the larger tax extender bill. Unfortunately, that was not enough for the two chambers to agree on a physician payment patch. House Republicans rejected the Senate’s two-month fix, scuttling any hope of reaching agreement by the end of the year as most Congressional members returned home to their districts this week for the holidays.

Congressional failure to agree on a “doc fix” by the end of the year could have created an enormous problem for physicians. Medicare physician reimbursement was scheduled to be slashed by 27 percent starting January 1, 2012.

Shortly after rejection of the Senate plan, House Speaker John Boehner (R-OH) called for a bi-partisan conference committee to be formed with the Senate to reach agreement on the SGR. House and Senate Democratic leaders rejected this idea, even as Boehner went ahead with appointing House Republican conferees. With physicians—and ultimately patients—facing such extreme cuts, Congress stood divided. At the last minute, Republican leadership back-tracked and agreed to a two-month extension.

The Centers for Medicare and Medicaid Services (CMS), having experienced brinksmanship over the SGR in the past, had decided to hold physician claims for 2012 services for the first 10 business days of January (ending January 17) to give Congress a little more time to pass an SGR fix. Inlight of the last-minute two-month temporary fix, this may not be necessary.

ACCC’s distaste for this Congressional inaction is shared by many other provider groups. The American Medical Association (AMA) said it well, calling it “shameful” that “Congress has again failed to fulfill its responsibilities.” In the end, I had hoped that Congress would get its act together and come to agreement at the eleventh hour–which legislators did–giving providers unnecessary gray hairs.

ACCC will be avidly watching for a longer term agreement, and we’ll be sure to keep members updated on this critical issue.

Cancer Management Systems: A New Value Proposition

REPORT FROM PHILADELPHIA

by Don Jewler, Director of Communications, ACCC

So, peer-directed, regularly updated oncology clinical pathways offer value to providers and payers. That was the gist of part one of ACCC’s December 8 seminar at the Fox Chase Cancer Center on cancer guidelines and pathways in the community setting.

The challenge is to integrate guidelines and pathways into oncologists’ workflow to provide ease of use and facilitate standardization of the process of collaborative care.

Enter cancer management systems, which are designed to create efficiencies, save money, and improve outcomes.

A number of companies are partnering with providers and payers to establish evidence-based oncology treatment protocols designed to offer standardized patient assessment and disease management support. Through cancer management systems, the protocols are integrated into daily workflow.

These cancer management systems “require a fully implemented oncology-specific EMR that interfaces with health systems, laboratory, outside radiology, and e-prescribing. The more sources of data that are automatically imported into the system the better,” said John D. Sprandio, MD, chief of medical oncology and hematology at Delaware County Memorial Hospital, where he also serves as director of the Delaware County Regional Cancer Center, a member of the Fox Chase Network.

According to Dr. Sprandio, cancer management systems also require:

• buy-in from providers to change their behavior
• a clinical decision-support system overlay that presents data to extract tasks away from clinicians that are not clinically relevant—like paperwork
• enhanced coordination and communication
• the ability to facilitate clinical goals and make patients the central focus of care.

In addition, they should fix accountability “on the shoulders of the physicians” and facilitate rational care decisions at the end of life.

Cancer management systems that meet these requirements can “lead to a new value proposition that you can present to payers as a higher quality service,” according to Dr. Sprandio.

Gurdeep Chhabra, MD, a medical oncologist/hematologist in Silver Spring, Md., uses a second generation cancer management system. His seven-member practice was involved in development of the first generation model, the first pathway program in the nation, through CareFirst and P4Pathways/CardinalHealth.

“Physicians were given financial incentives to participate in the CareFirst pathways first generation model. Physicians created their own pathways,” he said. The design included claims-based measurement that the physicians could view online.

Dr. Chhabra and his group wanted to move away from a traditional reimbursement model where the bulk of dollars comes from drug reimbursement margins. In the second generation model, they wanted additional incentives, end-of-life care initiatives, and a greater share of the revenue from the payer for the E&M codes they were responsible for.

Just six months in, it’s too early to determine the effect of the second generation model on quality of care. But it’s not too early to say that the new cancer management system resulted in a dramatic change in reimbursement structure and changes in practice, according to Dr. Chhabra. Analysis of E&M variation already shows increased revenues.

Ray Page, DO, PhD, president and director of research at The Center for Cancer and Blood Disorders in Fort Worth, Tex., uses a web-based cancer management system developed by D3 Oncology Solutions/Via Oncology Pathways. “With rapid growth over the last few years, we needed more consistency in practice standards to measure quality outcomes. We looked at pathways to differentiate our practice and lay the groundwork for new payment models for oncology care with United Healthcare. Our physicians have a seat on the table to develop the pathways and customize approaches.”

Dr. Page says the cancer management system allows him to identify more patients that are eligible for clinical trials and has enhanced accrual.

“If pathways sit on the shelf, they don’t help,” said Peter Ellis, MD, medical director for D3 Oncology Solutions/Via Oncology Pathways. “Docs need a delivery system that presents the pathway to make the physician’s life easier.”

Looks like cancer management systems are one option gaining ground in the oncology community to make the physician’s life easier–and to create value for patients and payers, too.

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ACCC’s seminar on “Navigating the Changing Landscape of Payment Models in Community Oncology” was sponsored by Cardinal Health/P4 Pathways; D3 Oncology Solutions/Via Oncology; ION Solutions; and McKesson Specialty Health.

Better Outcomes, Decreased Costs with Oncology Clinical Pathways

by Don Jewler, Director of Communications, ACCC

REPORT FROM PHILADELPHIA
Payment models in oncology are changing fast, driven by the high costs of oncology drugs, comparative effectiveness research findings, and variations in care. The 100 cancer care providers who gathered for ACCC’s seminar in Philadelphia were treated to an in-depth exploration of today’s shifting landscape in oncology reimbursement as well as the opportunities that new arrangements with insurers may offer.

The transformation will affect patients as well as providers. “We’re seeing pretty profound changes in benefit design,” said Donald Liss, MD, vice president for clinical programs and policy for Independence Blue Cross, the largest health insurer and managed care organization in the Philadelphia region. “High-deductible plans with employee-controlled spending accounts, consumer-directed health plans with high deductibles, narrow networks and increases in consumer cost sharings for health benefits.”

Employees contribute 45 percent more to their health plans than they did five years ago. From 2010 to 2011 the average employee annual premium payment increased 11.8 percent.

Providers will see increased use of bundled payments for a year’s worth of oncology care, for example, decoupling payments for drug and provider payment, more attention to precertification and accuracy in claims payment, and the promotion of adherence to accepted guidelines. Independence Blue Cross (IBC) “struggles with that,” Dr. Liss said of cancer management systems that integrate pathways into daily workflow. IBC receives “pitches” from a number of cancer management system companies to put a pathway program in place. “We look at these…We ask what are the consequences versus the benefits,” Liss said.

Why is cancer management needed? Costly drugs, for one.

“Looking forward to 2013, oncology is one of the seven therapeutic areas likely to drive the majority of drug spend 2011-2013,” said Amy L. Schroeder, RPh, senior consultant at DK Pierce & Associates, Inc.

She also cited variations in care as driving the transformation in oncology payment systems. “The use of chemotherapy in the last two weeks of life overall, for example, was about 6 percent of patients, but in some regions and academic medical centers the rate exceeded 10 percent. The use of hospice care varied markedly across regions and hospitals,” she said.

Comparative effectiveness research findings are also playing a part in payment model changes, said Amy Schroeder. The majority of employers expect CER findings to be used by their insurers.

Increasingly, commercial payers are finding value in clinical pathways. Most of the top insurers are initiating pathway approaches, focusing first on breast, colon, lung, and prostate pathways, said Amy Schroeder. Lymphomas, ovarian, and multiple myeloma are targets for expanded pathways in 2012.

Making decisions based on a clinical pathways program works well for Ray Page, DO, PhD, president and director of research at The Center for Cancer and Blood Disorders in Fort Worth, Tex. “Clinical pathways allow doctors to be more efficient in our practice. We are more predictable in our drug buys,” he said during a panel discussion.” The system also enhances his research program.

Panel participant Bruce Feinberg, MA, BS, MD, medical oncologist and vice president, CardinalHealth/P4 Pathways, used clinical pathways in his practice back in 1991, developed with a recognition that consensus would drive quality and that oncology is a complicated system. “Variance drives up costs of care, puts patients at risk. Clinical pathways can accomplish better outcomes…and decrease cost of care. That’s my experience,” he said.

Okay, so clinical pathways offer lots of benefits and provide direction in selecting appropriate care.

How can they best be integrated into provider business or web-based access?

Check back for the next blog.

The Holy Grail of Cost Savings in Oncology?

by Don Jewler, Director of Communications, ACCC

To help cancer care providers and pharmaceutical industry representatives understand the changing landscape in oncology payment, the Association of Community Cancer Centers (ACCC) is hosting a two-day seminar at the Fox Chase Cancer Center in Philadelphia, Pa., December 7-8, 2011. Day one’s common theme: Traditional reimbursement models are changing, and collaborative programs between payers and physicians are emerging because, in brief, clinical resources do not provide enough guidance, care varies widely, and oncology drugs are expensive.

“Providers want better outcomes, autonomy, and more payment,” said presenter Kurt H. Neumann, MD, FACP, vice president of Oncology Physician Resource and medical director for quality initiatives for ION Solutions, AmerisourceBergen Specialty Group. “Payers want decreased variability and increased predictability that money is being spent well.”

Increasingly, payers are using an evidence-based approach to guidelines and pathways that decreases cost trends. “If you can incentivize physicians to pick cheaper evidence-based pathways, you can save money,” said Dr. Neumann, although he acknowledged the difficulty of determining exact numbers.

Dr. Neumann knows first-hand about cost savings through pathways. He was co-medical director of the Michigan Oncology Clinical Treatment Pathways Program, a collaborative program designed to enhance the quality of care for patients with certain types of cancer.

To increase quality and cost-effectiveness, 190 oncologists in Michigan (community and academic practices) guided by a steering committee of 13, developed standard evidence-based, oncology clinical pathways over nine months in a stepwise process that would roll out over three years. All pathways were guided by efficacy first, toxicity second, and costs third. Pharmacy had limited input; third-party payers had no input. Clinical trials and hospice were considered within the pathways. In years one and two, clinical pathway compliance was required by breast, colon, lung cancer, and supportive care. In 2011 five new diagnoses were added.

Physicians had incentives to install new technology and make changes within their practice, according to Dr. Neumann. They were rewarded up front with $5,000 per participating physician. In 2011 the fee schedule was adjusted for generic products and gain sharing for participating physicians was increased an additional 10 percent. They had no incentive to prescribe expensive drugs.

“Every practice reached its compliance level. Using evidence base guidelines with concern for the total costs, the physicians decreased the variability, eliminated outliers, maintained autonomy, and achieved increased payments. I’m absolutely certain there is decreased cost,” said Dr. Neumann.

According to Dr. Neumann, the “Holy Grail” of cost savings from treating oncology patients is not from substituting similarly effective lower cost regimens for higher cost ones nor from appropriate dosing through evidence-based dosing. On the oncology continuum of care, savings of just 4 to 7 percent of the total oncology spend are achieved by substituting effective lower cost regimens for higher cost ones, appropriate dosing through evidence-based dosing, generic substitution when appropriate, and gene testing according to guidelines.

The Holy Grail of cost savings? According to Dr. Neumann, cost savings of 15 to 22 percent can be achieved by avoiding unnecessary inpatient admissions, working with patients and families to explain the benefits of end-of-life care, improving coordination between diagnosing and treating physicians to reduce redundant labs and imaging studies, reducing ER visits through well managed avoidance of side effects, and shifting to less invasive interventions.

Standardized care offers great promise for cost savings and quality care. The payback for creating guidelines and pathways that standardize care is great, said Dr. Neumann. The timeline, however, is years.

P.S. If you’re uncomfortable talking about costs instead of quality in patient care, don’t be. “Consideration of cost is not necessarily unethical,” said presenter David B. Wilson, RPh, Oncology Pharmacy Manager, at St. Luke’s Mountain States Tumor Institute, Boise, Idaho. He was quoting healthcare economist Michael Drummond, who also wrote: “Equity in healthcare may be desirable, but reducing inequalities usually comes at a price.”

Shining Light on the Mutational Landscape

by Don Jewler, Director of Communications, ACCC

As a lover of words and collector of neologisms, I was delighted with the new expression: “mutational landscape,” which appeared in a Medical News Today article on December 3 and brought to mind fields of talking corn or zombie attacks on our cities. The authors, however, were not writing science fiction. They used the term in reference to increased understanding of how certain mutations to cell DNA can cause cells to grow abnormally and form cancers. Charting a individual’s mutational landscape offers promise for determining which trials could help a patient the best as well as which treatments might be the most successful.

“We’re talking about more than just examining a few genes where mutations are known to occur, or even about a hundred genes. We’re talking about the ability to sequence more than 20,000 genes and look not just for individual genetic mutations, but at combinations of mutations,” said Dr. Dan Robinson, a post-doctoral fellow at Michigan Center for Translational Pathology (MCTP), quoted in the Medical News Today article.

Robinson co-led a study to solve the practical challenges researchers face in quickly and systematically sequencing genetic material from individuals suffering with advanced or treatment-resistant cancer so that they can be matched with existing clinical trials based on the biomarkers identified.

Practical challenges for researchers aside, knowledge and use of genetic mutation testing remain low among oncologists, nurses, and patients. New surveys* just released reveal a disconnect in understanding of and communication about genetic mutation testing among healthcare professionals and cancer patients, in this case patients with lung cancer.

The good news was that the vast majority of physicians responded that they discuss genetic mutation testing with their patients (94 percent) and with their peers during tumor boards (88 percent). The bad news: only 17 percent of lung cancer patients surveyed were aware of genetic mutation testing. Nearly half of oncology nurses (44 percent) did not discuss genetic mutation testing with patients, primarily because they felt that they lacked the knowledge to discuss it (56 percent) or didn’t have the proper resources to share with their patients (33 percent). These findings highlight the need for a greater understanding of genetic mutation testing.

Physician respondents identified a number of concerns related to genetic testing, including cost, reimbursement, and delays in initiating treatment. In addition, lack of tissue and multiple labs involved in testing create structural barriers to use of genetic mutation testing and establishing a treatment plan based on those results.

Although physicians may discuss genetic mutations with their cancer patients, some genetic tests may be underused, as we blogged in ACCCBuzz in October. One study showed that the assay to detect the presence of EGF receptor (EGFR) mutations in non–small cell lung cancer patients is vastly underused in the United States. Patients with EGFR mutations generally respond better to certain therapies – such as erlotinib (Tarceva) and geftinib (Iressa) – that target these mutations. Minorities and people with a lower socioeconomic and educational status, or those who live in rural areas, are not getting access to the EGFR test.

Bottom line: The more patients, physicians, and nurses know about genetic mutation testing, the easier it will be to properly diagnose and establish a treatment plan for the patient.

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*The surveys were done in partnership with the Association of Community Cancer Centers (ACCC), ONS:Edge, and the National Lung Cancer Partnership (NLCP), and sponsored by Boehringer Ingelheim Pharmaceuticals, Inc.

Exit the Super Committee

by Matt Farber, Director of Provider Economics and Public Policy, ACCC

OK, now what?

The Super Committee has failed. Congress was unable to come together to enact change, and the cuts to the Medicare program that the committee had been discussing are no longer being discussed. So, what does that all mean for community oncology?

Unfortunately, there are many cuts still on the horizon that will affect the cancer community. First and most time sensitive, is the SGR (sustainable growth-rate Medicare payment) formula. If Congress does not act by the end of the year, physicians will face a 27 percent reduction to the conversion factor. Many physicians have said that if this cut were to remain on the books, they would be forced to stop seeing or to curtail their Medicare patients. Congress for the most part is against these cuts, and they support fixing the program, at least in the short term. The problem, as with other issues facing Congress right now, is the cost. The cost to patch the SGR formula for a year is $22 billion. The cost to fix it outright is $300 billion over 10 years. Both parties in Congress have yet to announce how they would offset the cost of a one- or two-year fix, but it can and should be assumed that they will look to the Medicare program for possible offsets. In other words, in order to stop cuts to the Medicare program, they will cut the Medicare program. The cuts to the ASP+ number that the Association of Community Cancer Centers (ACCC) and others in the advocacy community have been fighting in the Super Committee? They may very well be back on the table for SGR.

And back to the Super Committee. It failed; so what? Well, as part of the law Congress passed in August of this year, if the Super Committee could not reach an agreement by Thanksgiving, thus not allowing Congress to vote on a package by the end of December, then an automatic trigger would go into effect. The trigger will automatically cut spending from all government agencies, with some facing upwards of 5 percent reductions. Medicare and Defense spending are included in the cuts, but these cuts are capped. Medicare, for example, will be cut by 2 percent. And, these cuts will go into effect on Jan. 1, 2013.

So, you may be saying to yourself, “2 percent does not seem so bad.” For some providers, that may be true. But when you look into what a 2 percent cut means, the reality is harsh. The 2 percent cut is not just off of the conversation factor, or just off of drugs; it is off the entire Medicare spend. Therefore, everything you bill Medicare for, from drugs to administration to evaluation and management to diagnostics, will be reduced.

But not so fast. Some members of Congress are already talking about passing a new law that would halt the trigger from taking effect in 2013. 2012 is an election year and cuts to Medicare, Defense, agriculture subsidies, and clean energy subsidies, for example, may be tough issues to run on for many members of Congress. The President has already said that he would veto any bill passed that would halt the trigger, so the road will be difficult.

So, getting back to the original question, “Now what?” The oncology community needs to remain engaged with their members of Congress. Let them know why they need to fix the SGR long term. Let them know what the 27 percent reduction would mean to you and your patients. And also let them know not to cut Medicare to save Medicare. Finally, start to look at what a 2 percent across the board reduction to Medicare reimbursements would mean for you as well. That information will be very useful in talking with Congress in the coming months. As always, ACCC will be the voice of the cancer care team and will continue to advocate on your behalf.

Is Oral Chemo a Better Option? Maybe Not

by Sydney Abbott, JD, Policy Coordinator, ACCC

Kate, a 51-year old mother of three had surgery to remove a brain tumor. Six weeks of daily doses of two oral chemotherapies cost $10,800. Her insurance company paid $2,000. Kate’s provider told her that if she had taken the identical drug intravenously, she wouldn’t have paid a dime.

“It wasn’t presented to me as an option to do it intravenously. They told me, this is what you do,” Kate said.

Kate’s story appears in an article by Robert McCartney in today’s Washington Post. Her experience with oral anti-cancer drugs and her complaint are shared by many other patients.

Currently, about 10 percent of chemotherapies are available orally. However, up to 35 percent of agents in oncology development are oral medications. As more oral therapies emerge, many health plans are creating inequity and access problems for patients by covering infused chemotherapies at significantly lower out-of-pocket patient expense than oral agents.

Injected or infused treatments are typically covered under a health plan’s medical benefit, so patients are responsible for the office visit co-pay but not required to pay for the drug itself. Oral medications, however, are generally covered under a plan’s pharmacy benefit. Some plans require very high monthly co-insurance for prescription drugs, often thousands of dollars out of pocket for the patient each month.

Medicare has already fixed this problem. Under Medicare Part D, any oral chemotherapy drug that is identical to an intravenous chemotherapy drug is covered under Medicare’s medical benefit, Part B. H.R. 2746 is currently making its way through Congress to correct this issue for private payers, as well. It would require group and individual health insurance plans to provide for coverage of oral anticancer drugs on terms no less favorable than the coverage provided for intravenously administered medications.

Since 2007, 14 states* and the District of Columbia have passed oral chemotherapy drug parity laws.

That’s not enough. The Association of Community Cancer Centers (ACCC) wants to see every state with laws on the books protecting access to oral chemotherapy options for cancer patients. We will continue to fight to preserve your ability to prescribe the most appropriate treatment for your patients. ACCC will continue to stay on top of this topic and will notify members of state efforts as they become available.

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*Colorado, Connecticut, Hawaii, Iowa, Illinois, Indiana, Iowa, Kansas, Minnesota, New Mexico, Oregon, Texas, Vermont, Washington