By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
The failed debt negotiation talks of 2011 led to the 2% across-the-board Medicare sequester that has been squeezing the oncology community since CMS implemented it in April 2013. Shortly after the sequester began, ACCC surveyed its membership across varying sites of care and found that close to 60% of respondents reported being impacted by the 2% reduction in Medicare reimbursement. In October, when sequestration hit the six-month mark, ACCC conducted a follow-up survey of its membership to see how cancer programs were coping and if the picture painted at the start of the sequester still stood. The results of the follow-up survey highlight some interesting points about how the sequester is impacting community oncology care.
Two-thirds of survey respondents report being impacted by the sequester. Of those impacted, 84% are making adjustments to operating expenses, including reducing staff hours or not replacing staff when they resign. The follow-up survey results show the fastest growing area seeing cuts is non-revenue-generating programs, such as patient navigation services. Reducing these services hinders the quality of care for all cancer patients since these programs help patients with financial, dietary, cultural barriers, health literacy and other needs. These programs assist all patients in a cancer program; therefore, it is not surprising that 75% of respondents said the sequester is impacting every one of their patients, even though the 2% reduction in reimbursement is applied only to Medicare claims. This is an increase of 15% from the initial survey, showing that some of the broader implications of sequestration are just beginning to surface.
Interestingly, in the follow-up survey, of those who had not yet made changes, one-quarter responded that they did not expect to make changes in the future, as compared to 14% in the earlier survey. This may be good news indicating that more cancer programs are finding ways to adjust to these reimbursement reductions without making changes to patient care.
These results show that many ACCC members are resourceful and are coming up with innovative solutions to continue to care for their patients. However, overall, the results of these surveys show that more cancer facilities are being negatively impacted as a result of the 2% cut to Medicare reimbursement through sequestration, and that the cuts have impacts far beyond Medicare patients—they extend to all patients, to staff, and to supportive care programs. Providers are at the end of their rope—community oncology care cannot be cut further and the sequester must be reversed to preserve patient access to the supportive care services that relieve barriers to care, increase value, and help reduce long-term costs.
Please contact your legislators to let them know how the sequester is impacting you and your patients. ACCC will continue to encourage Congress to protect patient access to care by protecting community cancer care reimbursement.
By Virginia Vaitones, MSW, OSW-C
‘Tis the season. As the TV, radio, and shopping malls are bombarding us with Christmas music and Black Friday shopping deals, I would like to take this moment—a few days before the Thanksgiving holiday—to reflect on “thanksgiving” and its importance to us in the field of cancer care. The first Thanksgiving was a celebration of survival and good harvest. It was also a time of sharing and caring for one another.
Every day, those of us working in cancer programs around the country celebrate the courage of our patients and their caregivers, as they travel down a road paved with unknowns, challenges, and adversity. And we recognize that, today, there is much to give thanks for as the arsenal of treatment options against this disease continues to expand.
Finally, we are thankful for the support and strength that comes from being part of a multidisciplinary team of care providers. As one of my patients was leaving the other day, she turned to her husband and said, “I have a terrific team.” As President of Association of Community Cancer Centers, I would like to say “thank you” to all of the “teams” of multidisciplinary cancer care providers and to each team member for the care you provide to patients and their caregivers. I wish you and your loved ones a joyful Thanksgiving.
Virginia Vaitones, MSW, OSW-C, is President of the Association of Community Cancer Centers, and an oncology social worker.
by Diane M. Otte, RN, MS, OCN
Outreach and information on skin cancer awareness and melanoma typically “heat up” as summer approaches, not as we—in most of the country—are bundling up for winter weather. Still, for community cancer programs caring for patients with melanoma, the disease knows no season. This month ACCC is providing a new resource aimed at helping cancer programs improve the melanoma patient experience.
Those of us who have spent most of our careers in the oncology field have experienced firsthand the changes in our awareness of sun safety and skin cancer prevention. If you’re like me, you can look back to those days as a teenager when you worshipped the sun without any regard for the “bad effects.” Sunscreen? None of that. Instead, you slathered on the baby oil, used foil to enhance the effect, and even if the day was cloudy and chilly, you found a spot to indulge in sun worshipping!
How far we’ve come—in our awareness of the risk we took then and in how we can educate our children, grandchildren, friends, co-workers, and others about skin cancer—especially one of the most serious and dangerous types—melanoma! If you think about your own oncology practice, each of you could tell the story of a patient who touched you and influenced your view of this ever-increasing disease. I remember clearly a young woman in her twenties, diagnosed when pregnant with her second child. She had a two year old at home and was several months pregnant when the diagnosis was made. I don’t remember all the details of her story but I do remember the impact she had on our staff as she valiantly fought this disease…unfortunately, she lost the fight many months later.
Now, several years later, I’ve added our dermatology practice to my cancer program management responsibilities and have learned how significantly melanoma is increasing in our population—1 in 50 Americans has a lifetime risk of developing melanoma. As you look around you, my hunch is that you personally know someone who’s been diagnosed with melanoma.
ACCC’s new resource, “Melanoma: Improving the Patient Experience, Practical Strategies for Community Cancer Centers,” provides practical information that community-based oncology programs can use. The effective practices highlighted in this publication focus on a multidisciplinary approach to care, access to clinical trials, patient navigation services, supportive care, and use of clinical guidelines as well as the expertise of regional experts. Six ACCC-member cancer programs of various sizes and geographic locations share details about their programs and discuss strategies for the management of patients with melanoma as well as barriers to care. A pre/post assessment of effective practices and a checklist for use in implementing effective practices are included.
Hopefully each of us has changed our own personal sun worshipping habits and now don appropriate clothing and protection when in the sun. With this new resource, developed as part of ACCC’s Melanoma: Improving the Patient Experience project, I also challenge you to take the time to assess, within your own practice, how well you are serving your patients with melanoma and making the changes needed to educate your staff and the community around you. By working diligently to address the barriers and needs of this patient population we can make a difference.
Diane Otte, RN, MS, OCN, serves on the Advisory Board for ACCC’s Melanoma: Improving the Patient Experience project. She is Director, Cancer Center & Dermatology, Mayo Clinic Health System-Franciscan Healthcare Cancer Center, and has served on the ACCC Board of Trustees.
by Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
1) There is now bipartisan, bicameral legislation to reform the sustainable growth rate (SGR) that does not give Congress sticker shock; and
2) The U.S. Department of Health and Human Services (HHS) has declared that that it does not consider health insurance plans and other related federal subsidies that are offered through the new insurance exchanges, to be federal healthcare programs.
The House Energy & Commerce, Ways & Means, and Senate Finance Committees have worked together to introduce policy to repeal the flawed SGR formula with stable payments and quality-based incentive payments moving forward. Energy & Commerce was the first to introduce legislation in September, but the Congressional Budget Office (CBO) estimated the bill would cost $35 billion more over 10 years than the CBO’s most recent scoring for an SGR fix. Now, the Ways & Means and Senate Finance Committees have introduced new legislation more in line with the CBO’s anticipated costs.
This proposed legislation would prevent the 24.4% cut to reimbursement – which is currently set to go into effect on Jan. 1, 2014, unless Congress steps in. Under the new legislation, the SGR formula would be replaced with a pay freeze for the next 10 years. The proposal, which is still in discussion draft form, calls for gradually replacing Medicare’s existing fee-for-service payment system with a “value-based performance system” focused on medical outcomes rather than procedures. This means there will be financial incentives to participate in alternative payment models. Under the draft legislation, it’s possible that reimbursement could be adjusted based on performance as soon as 2017. The bill relies on the Physician Quality Reporting System (PQRS), the value-based modifier, and the EHR Meaningful Use Program – currently penalty-only systems – to create incentive payments for high-quality care. In addition, the proposed legislation would keep the penalty portion of these programs to help fund the incentive payments.
We can all agree that the current SGR formula is fundamentally flawed and that a new reimbursement system is necessary. The CBO has estimated the cost of “freezing” physician Medicare payments for 10 years at $138 billion. While this is a relative bargain in congressional terms, Congress still faces an uphill battle to find the funds to replace the SGR. To date, the draft legislation addresses the policy behind SGR reform only; the battle to identify a ‘pay-for’ has not yet begun.
Exchange Plans Not Federal Programs
With the new insurance exchanges, there has been much confusion concerning whether drug manufacturers would be able to continue certain patient assistance programs because it was unclear whether the new insurance exchanges and their related subsidies were considered federal programs. Generally, drug manufacturers can provide copay assistance to patients who are unable to afford their medication so long as they are not in receipt of assistance through a federal program. Although the insurance plans purchased through the exchanges are private, the fact that they are being offered through a federal marketplace and federal funds are available to offset the cost of premiums led to many unanswered questions. Many drug manufacturers wondered if they would be able to continue to offer patient assistance programs to these needy patients.
Thankfully, in a letter to Congressman Jim McDermott, HHS clarified that qualified health plans and related federal subsidies are not considered federal programs for the sake of manufacturer copay assistance programs. This is great news. The clarification means that drug companies may continue to offer the much needed assistance that many low-income patients have come to rely on.
So forget about the federal government shut down, looming debt ceiling, and other congressional woes for a few minutes. With Thanksgiving approaching, let’s be thankful for a few of the bright spots coming from Washington and, for the moment at least, view the glass as half full.
by Matt Farber, Director, Provider Economics and Public Policy, ACCC
The role of technology in healthcare—and the many headaches that can accompany the adoption of new technology—has been put under the microscope in recent weeks. Missteps and glitches during the roll-out of the new health insurance marketplaces’ online enrollment have some questioning broadly whether technologies designed to improve the healthcare system can actually achieve their goal.
The process may not be easy, but evidence shows that appropriate technology can improve efficiency and coordination in healthcare, whether it’s online insurance enrollment, electronic health records, or—as explored in a new white paper from ACCC—health information exchanges.
ACCC’s new white paper, “Cancer Care in the Age of Electronic Health Information Exchange,” discusses the potential impact of health information exchange on cancer care and the hurdles to adoption. It is the second white paper to come out of ACCC’s Institute for the Future of Oncology, with the first released in October.
Health information exchange describes two related concepts: the electronic sharing of health-related information among organizations, and the entities that provide services to facilitate this electronic information sharing.
“Cancer Care in the Age of Electronic Health Information Exchange” explores the current state of health information exchange adoption, the importance of HIE, and also the potential for improved quality of care and reduced costs that an HIE can provide.
The push for adoption and integration of electronic health records (EHRs) has been a first step toward realizing the capabilities and benefits of electronic health information exchange. Adoption of and engagement in HIEs, the organizations that enable electronic sharing of patient data across providers and healthcare organizations, is the next step—and in many areas of the country, this step is still out of reach.
The white paper reflects discussion and perspectives from participants in the Institute’s inaugural forum, which was held in late June 2013. Here is a snapshot of the white paper’s findings:
- HIE adoption is uneven.
- There is a lack of awareness around HIEs.
- HIE initiatives must focus on information standardization.
- HIEs can help benchmark interventions within patient populations.
- Providers must have input on the information released via patient portals.
The potential of HIEs to improve benchmarking, efficiency, and ultimately quality of care in oncology was universally agreed by participants at the Institute. However, the consensus was that many hurdles remain before the potential becomes reality.
ACCC’s Institute for the Future of Oncology addresses key topics impacting oncology now and in the future. If you would like to get involved in upcoming forums of the Institute for the Future of Oncology, please contact Matt Farber at firstname.lastname@example.org.
On October 4 ACCC hosted a lively town hall discussion featuring panelists Michael Kolodziej, MD, FACP, Aetna; Stanley Marks, MD, UPMC Cancer Center; Kim Thiboldeaux, Cancer Support Community; and Byran Litton, MBA, Eli Lilly & Company. The panelists, representing different stakeholders in the oncology community, discussed the challenges of the current healthcare payment system and explored future models.
The conversation, moderated by William T. McGivney, PhD, focused on the transformative shift underway in healthcare payment systems as reimbursement moves from volume-based, fee-for-service models to new value- and quality-based payment methodologies.
Panelists agreed that the current payment system is broken and that migration from a system that rewards volume to a system that reimburses for quality and value is necessary.
But when challenged to come up with solutions that could be put into action in the next 18 to 24 months, panelists’ perspectives diverged.
Dr. Kolodziej’s first step would be to put all health information and all financial transactions in the healthcare system on the same electronic platform with information communicated in real-time and transparency for all stakeholders. With fully integrated, accessible health information exchange, stakeholders could move forward in defining value and use data to make intelligent decisions about next steps. In fact, Aetna has already taken a step in this direction and purchased a health information exchange, he said.
For Kim Thiboldeaux, achieving payment reform, improving quality, and decreasing cost will take putting the patient truly at the center of care. To do this, the system needs to incorporate and pay for those low-cost, high-touch, high-impact psychosocial interventions that have proven to help reduce costs and help patients with adherence to their therapies, she said. Thiboldeaux also emphasized the need for a new approach in cancer patient education. “It’s time to move to patient education 2.0,” she said. This means providing patients with tools and resources to help with access issues; to understand step therapy, fail first therapy, and how comorbidities affect treatment decisions, for example. “I think we sometimes underestimate our patients and underestimate their ability to take in information. I think that particularly in oncology we have a very educated patient population.” In the transition to new value-based payment systems, patients must be empowered with tools and resources to be informed partners in treatment decision-making.
From Dr. Marks’ perspective, needed steps to revamp the payment system are standardization of care, reduction of waste, and incentives for physicians to save money. “Our volume-driven payment system is flawed and the incentives are perverse. Everything today is driven by volume, more chemotherapy, more surgery, more imaging. We need to get away from the volume driver and move toward quality,” he said. While incentivizing physicians to save money is essential, he noted that any transition to new payment models must involve physicians in leadership roles and that, for new models to succeed, physician buy-in is essential
If he had a mandate to create an immediate solution to current payment system challenges, Byran Litton said restoring reimbursement to ASP+6 percent to relieve the financial pressures on practices that are struggling to survive under ASP+4% would be the first step. He would follow this with a push to reach consensus on quality measures. “I think whatever we do has to be applicable in both the community and hospital setting. I think we have to amplify the patient voice. I think whatever we stand up for has to allow innovation to flourish.”
Will there be enough dollars in the system to cover the cost of all these changes (incentives, pay-for-performance, and innovation under new payment models that reimburse based on value and quality)?
The short answer, panelists agreed, is: “Yes.”
Reduce the waste in the current system, and money will then be freed for innovation and to reward high-performing providers.
“I think the money is there,” said Dr. Marks. “There is just so much waste.”
He pointed to reducing expenditures in such areas as hospitalizations and ER visits, and use of high-cost drugs that have demonstrated very little benefit to the patients. “If we restructure this and get away from driving volume and focus more on quality and standardizing care,” the money is there, he said.
Who will drive these changes? Who will stand up for patient access, physician autonomy, innovation, an efficient healthcare system—and ensure that all of these things are blended together? In short, how will stakeholders reach consensus for change?
“Will we have to throw everyone into a room together?” McGivney asked.
“I think there’s got to be a “kumbaya” moment,” said Kim Thiboldeaux, pointing out that each of her fellow panelists represented a different stakeholder group, each with a say in payment reform and each with a stake in the outcome.
“We’re talking about pathways, evidence-based care, unit cost, and patient preferences. I think all those things weigh in to how we’re going to reform the system so we can get to a place where we can all live. We can all walk away achieving our goals—maybe some will walk away with a little less than they thought they would or intended to. In the beginning, we will all have to make some choices and sacrifices, including patients. . . . We all have a stake in it, and we all have to come together in the solution,” she said.
To watch the full discussion, click here.
By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
The federal government is back in business. On Wednesday evening of this week, the House and Senate passed a continuing resolution to fund the government through January 15, 2014, and raise the debt ceiling until February 7, 2014. So, the shutdown is over, but Congress essentially just kicked the can down the road—and not very far.
The good news? Funding for new clinical trials will be restored and the Centers for Medicare & Medicaid Services (CMS) will get back to writing the final rules for the 2014 Physician Fee Schedule (PFS) and Hospital Outpatient Prospective Payment System (OPPS). However, funding has been restored at post-sequestration levels, and the conversation continues about how this is impacting community cancer care. It’s also possible that the three-week government shutdown may cause a delay in CMS’s release of the final rules, which would mean less time for implementation of the new policies that go into effect on January 1, 2014.
What about hopes for SGR reform? With less than two months remaining in 2013 and Congress focused on little besides the budget and debt ceiling, hopes of passing reform this year are slipping away. This means we are looking at the probability of yet another last-minute “Doc Fix” to stave off the anticipated 25% cut to Medicare reimbursement created by the flawed SGR formula. This year, many in the advocacy community believed that the timing was ripe to finally do away with the SGR given the CBO’s low budget score and the fact that the House Energy & Commerce, Ways and Means, and Senate Finance Committees all drafted legislation. While there is an outside chance that SGR repeal could get looped into a larger budget deal, the current SGR repeal legislation is expected to cost $175 billion over 10 years and no offsets have yet been identified, so Congress will likely wait another day to take on that fight.
Déjà vu all over again? Come January we may see ourselves in the same situation from which we just emerged: partisanship and political gridlock threatening another shutdown. While the conversation on the Hill continues to be budget-driven, ACCC will continue to work with members of Congress to preserve provider reimbursement and access to care for patients. We will be participating in a Hill day next week with other members of the cancer advocacy community to request adequate funding for cancer research and other programs. Please stay tuned for updates.
By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
As you undoubtedly already know, we are in the third week of the government shutdown due to Congress’s inability to agree on a continuing resolution (CR) to fund discretionary spending. This means that discretionary spending has stopped, but mandatory spending for things that protect life, property, and entitlements continues on an automatic basis. What does this mean for cancer care providers?
1) At least in the short term, Medicare reimbursement will continue as usual (at post-sequestration levels).
2) The National Institutes of Health (NIH) will continue with clinical trials currently in progress, but will not begin any new trials until funding is restored.
3) The U.S. Food and Drug Administration (FDA) has furloughed a number of workers, which could slow the approval of new drugs if there is a prolonged shutdown.
The federal government is expected to hit the debt ceiling—the point at which the country cannot borrow new money—on October 17. Speaker Boehner has committed to not reaching the debt limit, even though the House and Senate are still unable to reach a deal that pleases everyone. Some members of the House Tea Party remain committed to only voting in favor of funding if implementation of the Affordable Care Act (ACA) is delayed. Current negotiations would fund the government through the middle of January, and raise the debt ceiling through the middle of February; barely enough time to catch a breath before the threat of shutdown is upon us again.
While Congress continues to negotiate the government’s budget and borrowing limit, other important legislation waits on the sidelines. The status of the sequester remains of specific interest to the oncology community. ACCC continues to support HR 1416, legislation that would exempt cancer drugs from the Medicare sequester. This legislation is becoming increasingly important not only because of its 108 bipartisan cosponsors, but because of the current political climate. Congress is in a deficit-reduction mindset. While they understand that the sequester is a blunt budgetary tool which impacts oncology providers in a particularly unfair manner, they are reluctant to eliminate the sequester because it is saving the government money. In other words, Congress views the sequester as the new normal and proved this by only introducing budget bills with post-sequestration spending levels.
Cancer care providers, please complete ACCC’s follow-up sequester impact survey so we can show how the two percent Medicare sequester is impacting you and your ability to care for patients. As always, ACCC will keep members up to date on this important matter.
by Amanda Patton, Manager, ACCC Communications
An expert panel—representing the payer, private practice, hospital-based cancer program, academic medicine, and the patient advocacy perspectives—discussed Innovation: Value, Quality, and Technology on Thursday, Oct. 3, at the ACCC National Oncology Conference in Boston, Mass. Echoing keynote speaker Whitney Johnson’s theme of disruption and innovation, panelists identified major disruptors to the status quo and multiple constraints challenging oncology care delivery.
Disruption is not limited to oncology. “It’s our entire medical system,” said panelist Roy Beveridge, MD, Senior Vice President and Chief Medical Officer, Humana, Inc. “It’s a brave new world and the next five years will be very exciting.”
Specific disruptions cited by panelists included changing relationships between primary care providers and specialists, hospitals and payers, and providers and payers. Added to this are overarching uncertainties about reimbursement, how (or if) the sustainable growth rate (SGR) fix will be achieved, and the impact of the newly created health insurance exchanges on oncology providers and the patients they serve.
Panelist Al Benson, MD, FACP, Professor of Medicine, Northwestern University’s Feinberg School of Medicine, sees constraints ahead in three main areas: patients having to deal with fragmentation of services, workforces shortages, and technology-driven challenges. “Technology is really overwhelming, and I wonder how a general medical oncologist is going to adjust to these massive changes. With more diagnostic tools, it’s not only how we’re going to afford them, but how to integrate the technology into healthcare structures so patients can move through the system more efficiently.”
Nancy Davenport-Ennis, CEO of the Patient Advocate Foundation (PAF), shared the patient advocate perspective. “Disruption for patients begins the day their name and cancer is said in the same sentence,” she said. For her organization, a major challenge has been the accelerated growth of uninsured patients over the past year. Thirty-eight percent of patients served by PAF in 2012 were uninsured, she said.
Panelists also discussed the evolving provider-payer relationship. Quality care does not have to be expensive care, panelists agreed.
Partnering with a payer, a provider can demonstrate quality metrics and use of pathways, commented panelist Kim Woofter, RN, OCN, Chief Operating Officer, Michiana Hematology Oncology. Through participation in Health Information Exchanges (HIEs) practices can integrate with other providers to streamline patient enrollment in clinical trials, as well as partner with hospitals to reduce hospital re-admission.
Panel moderator Cliff Goodman, PhD, the Lewin Group, asked panelists to share innovations they’ve developed in response to these challenges.
Given the fragmentation of the current delivery system, Norma Ferdinand, Senior Vice President, Lancaster General Health, said her heath system is responding by supporting a culture of innovation and learning. The health system recently opened a new cancer center to centralize services with a patient-centered, rather than physician-centered design. The system is also participating an accountable care organization, among other initiatives.
Kim Woofter said her practice has taken ownership of care coordination in the period immediately after hospital discharge. A large triage staff handles the 48 hours post-discharge, following up with patients to ensure they have needed medications and resources. “We can affect return admission by interacting with that patient within the first 48 hours after discharge,” she said. Participation in a Health Information Exchange (HIE) is also facilitating the practice’s ability to demonstrate quality to payers.
Davenport-Ennis described a range of services PAF is providing including 24/7 patient portals, online easy-to-use tools for consumers, and more.
A key takeawy from the discussion: Innovation at the nexus of value, quality, and technology requires a patient-centered, data-driven, learning organization.