By Becky L. DeKay, MBA, President ACCC
The Association of Community Cancer Centers (ACCC) has just released its 2014 Trends in Cancer Programs survey results, and our membership revealed what matters to them most—delivering quality, patient-centered care. ACCC’s annual survey provides insight on the top issues facing cancer programs today, from clinical trial accrual, to expanding use of oral oncolytics, to providing financial advocacy services, and much more.
My presidential theme during my 2014-2015 term is quality cancer care, and I firmly believe that quality is a journey, not a destination. With this in mind, an analysis of these survey results reflects how our members are continuously striving to deliver quality care with a variety of forward-thinking solutions.
One compelling new trend among cancer programs—an increasing number are proactively developing their own guidelines to help measure and track the quality of care provided, rather than waiting to be told what to do by payers. This determination to anticipate the changing healthcare landscape and to grow is encouraging; especially since only 28% of respondents reported that payers currently require quality measures.
At Feist-Weiller Cancer Center we have participated in ASCO’s Quality Oncology Practice Initiative (QOPI) to gauge our quality in clinical care, and have done very well. We also have patient satisfaction surveys, and usually our scores are high. What keeps me up at night, though, is that we are unsure as to how best present this data to our various stakeholders who define quality care in very different ways.
For example, while “trastuzumab for patients with AJCC stage I (T1c) to III HER-2/neu positive breast cancer” may make sense to clinicians—payers and patients may not understand the clinical decision making for an expensive drug that is not without side effects. And when the patient spends more than 30 minutes in an exam room, many payers on the “judging” side (or clerical staff entering the data reported) won’t know that this reflects the fact that the patient needed more time with the physician team before making an informed decision and not that she was just waiting for a physician to arrive.
One thing all stakeholders agree on is the importance of patient-centered care. Our patients’ needs are not solely medical, a fact many cancer programs have started to address. In ACCC’s 2014 Trends in Cancer Programs survey, an increasing number of cancer programs report that they are stepping up their efforts to ensure that they are ready for the American College of Surgeons’ Commission on Cancer (CoC) standards that go into effect in 2015, including those related to palliative care, clinical trials, patient navigation, cancer survivorship, and genetic counseling. The survey also suggests that patient-centered care is driving growth in the number of supportive services being offered, including integrative and complementary therapies. This year’s survey shows that the patient-centered field of financial advocacy is thriving, with 90% of survey respondents offering financial assistance services, and 84% reporting that they have “financial specialists” on staff.
As ACCC continues to solicit feedback from its members, I hope that you will find this survey a useful resource to comprehensively evaluate your organization’s performance.
This is year five of the survey, which is a joint project between ACCC and Lilly Oncology. More than 110 ACCC-member cancer programs participated in this year’s survey. Learn more here.
Becky L. DeKay, MBA, is ACCC President (2014-2015) and director of oncology services at Feist-Weiller Cancer Center in Shreveport, La.
by Don Jewler, Guest Blogger
In case you didn’t notice, the cancer clinical trials infrastructure across the country is changing.
In August 2014 the National Cancer Institute (NCI) awarded 53 new five-year grants to researchers across the country to conduct multi-site cancer clinical trials and cancer care delivery research studies in their communities. The grants were awarded under the NCI Community Oncology Research Program (NCORP), a national network of investigators, cancer care providers, academic institutions, and other organizations that provide care to diverse populations in community-based healthcare practices across the United States. The program funding is $93 million a year for five years.
“I’m cautiously optimistic,” said Nicholas J. Petrelli, MD, FACS, who will be presented with ACCC’s 2014 Clinical Research Award at the upcoming 31st National Oncology Conference, in San Diego Calif., October 8-10, 2014. “With developments in genomics and in the infrastructure of NCORP, perhaps we can make a dent in overall survival in many of the solid tumors, beyond two- and three- and four-month survival, especially in the top five cancers we see in this country.”
Dr. Petrelli is also optimistic in the area of cancer prevention. “We spend so much effort and so much money on advanced disease and even early-state disease that we are long-overdue for a paradigm shift towards prevention. Perhaps as we enter into the world of proteomics and genomics, we will be able to do a better job at preventing the top cancers. I’m hoping that NCORP will move us forward on this front.”
Thirty-four NCORP Community Sites and 12 Minority/Underserved Community Sites will implement the latest, most scientifically advanced clinical research designed and led by NCORP. These clinical trials will bring added opportunity to test new technologies and strategies to fight cancer. They will also enable research on how cancer care is delivered in today’s changing healthcare environment, all with an eye toward improving outcomes and reducing disparities of care.
NCORP replaces two previous NCI community-based clinical research programs: the NCI Community Clinical Oncology Program (CCOP, made up of the Community Clinical Oncology Programs, Minority-Based Clinical Oncology Programs, and Research Bases) and the NCI Community Cancer Centers Program (NCCCP). The new program builds on the strengths of the previous programs and aims to better address the most pressing issues affecting the conduct and delivery of cancer care in communities across the nation.
With the 34 NCORP Community Sites and a realignment of the cooperative groups, Dr. Petrelli hopes to see a rise in the annual 4 percent national accrual average of adults on clinical trials.
A major sticking point remains: adequate funding.
“We’re running on a quarter tank of gas with NCORP, and that’s not going to get us too far,” said Dr. Petrelli. “There’s got to be a change in funding at the federal level in order for the program to be successful; otherwise, we are spinning our wheels.” What’s more, he noted, we will have to find a way for hospitals not funded by NCORP to continue their infrastructure of clinical trials.
Dr. Petrelli expressed hope that resources will improve as NCORP’s infrastructure begins to grow.
As for the opportunities ahead for clinical cancer research, Dr. Petrelli singled out his top two. “First, we need to evaluate the costs of what we are doing,” he said. “We need to evaluate patients as they go through treatment—how often they get imaged or blood drawn, for example. We need to take a hard look and be very practical in the management of costs. Second, genomics, which will allow us to move faster with regard to overall survival,” as genomic data helps us improve cancer prevention, early detection, diagnosis, and treatment.
Dr. Petrelli is the Bank of America endowed medical director of Christiana Care’s Helen F. Graham Cancer Center & Research Institute in Newark, Delaware. The institution earned a five-year grant from NCORP to bring leading-edge cancer screenings, prevention, control, treatment, and imaging research trials to more people in the places closest to where they live.
Hear more from oncology thought-leaders at the ACCC National Oncology Conference, Oct. 8-10, 2014, in San Diego. Learn more here.
ACCC members will recognize the byline of guest blogger, Don Jewler, former ACCC Communications Director. We coaxed Don out of retirement to contribute to ACCCBuzz.
by Amanda Patton, Manager, Communications, ACCC
The language delaying implementation of ICD-10 that was piggy-backed on last week’s SGR “patch” legislation caught many off guard. With months—if not years—of preparation and planning for implementing the new code set—it seems we’re back to uncertainty. ACCCBuzz asked Cindy Parman, CPC, CPC-H, RCC, to share her thoughts on the delay and next steps for cancer programs. Parman is a principal at Coding Strategies, Inc., and authors the “Compliance” column for ACCC’s journal, Oncology Issues.
ACCCBuzz: What are your thoughts on this latest delay by Congress?
Parman: First, it isn’t over until it’s over. The Centers for Medicare & Medicaid Services (CMS) has not weighed in yet [at the time this post was written] on what the inclusion of ICD-10 delay language in the SGR fix legislation really means. At present, several news sources have suggested that the agency’s silence on the never-ending drama—termed by one publication as “ICD-10 Held Hostage”—could mean:
- There will be an official implementation delay until October 1, 2015, or
- CMS will establish a different mandatory/voluntary implementation scheme, or
- CMS will decide to allow those providers who want to voluntarily implement ICD-10 on October 1, 2014, to do so, or
- CMS will decide that the legislation is not valid, since there was no Federal Register announcement, no comment period, etc., and
- Other payers may decide to “go live” on October 1, 2014, regardless of the SGR patch legislation that affects only the Department of Health & Human Services (HHS).
ACCCBuzz: Assuming that ICD-10 implementation is delayed, what does that mean for hospitals and physician groups who have already invested in computer system upgrades, clinical documentation improvement, and coding education?
Parman: According to the American Health Information Management Association (AHIMA) in a March 31, 2014, email to its membership:
Effects of a one year delay include an estimated likely cost of $1 billion to $6.6 billion to the healthcare industry and lost opportunity costs for failing to move to a more effective code set. A cloud will also be cast over the employment prospects of more than 25,000 students who have learned to code exclusively in ICD-10 in HIM associate and baccalaureate educational programs.
ACCCBuzz: So what should oncology providers do now with respect to the ICD-10 transition?
Parman: It’s important to stay the course. Shelving the work completed so far and losing the financial investment is simply not an option! Here are some tips to help:
- Keep working on clinical documentation improvement (CDI). This is not just a project that affects ICD-10; it affects quality reporting, value-based modifiers, responses to audits and investigations, patient portals, and almost every other aspect of healthcare. Practices and facilities who have not implemented a CDI program should get the ball rolling as soon as possible. (Find out more about why you need a CDI program here.)
- Know the ICD-9-CM Official Guidelines for Coding and Reporting! The ICD-10-CM Official Guidelines include some changes to sequencing, mandatory assignment of additional diagnosis codes for tobacco and alcohol use, etc., but they are built on the same format and structure. As a compliance consultant that performs both radiation oncology and infusion center chart audits, I rarely see correct and complete ICD-9-CM diagnosis coding. If a facility or practice is completely documenting all primary, secondary, and tertiary medical conditions with ICD-9, the transition to ICD-10 will be so much easier.
- For those providers who have initiated or completed training on the ICD-10 code set, it is use it or lose it. Make certain that coding staff continues to use the ICD-10-CM code set, by dual-coding a subset of medical records, performing peer review of records coded with ICD-10, etc. Do something creative, like a weekly Lunch-and-Learn to discuss unique ICD-10 coding situations.
- For those providers who have not initiated or completed training on the ICD-10 code set, don’t wait – just do it. The whole point of any transition delay is to maximize the remaining time to complete the task. This is a larger coding classification than ICD-9-CM with variances in the verbiage and specificity of available codes. Don’t underestimate the extent of education required, and don’t wait until the last minute and assume that there will be training programs available.
- Continue to perform end-to-end testing with those payers who are ready for this. Test often with any payer that is available for testing, and set up a process for denial management. There is a potential for an increased number of denials with the implementation of ICD-10, so make sure your denial management process is efficient and accurate. Of course, the best way to manage denials is not to have any, so use this gift of time to also improve front-end processes to minimize rejections and denials.
- Facilities who have completed the computer system updates, clinical documentation improvement, and most or all of the coding education can consider “backtrack” diagnosis coding. This means that the medical coding staff reports ICD-10-CM diagnosis codes, but the software backtracks and bills the ICD-9-CM code. This is a much easier conversion process (to go from one detailed code back to a more general diagnosis code) and can be accomplished by many existing billing software engines. If this process is initiated during calendar year 2014, the actual transition to ICD-10, when it finally occurs, may be smooth and straight-forward.
ACCCBuzz: What about those who say, “Why not just wait for ICD-11?”
Parman: Have you seen ICD-11? It is built on ICD-10, so be careful what you wish for! Attempting to transition from the ICD-9 classification directly to ICD-11, and bypassing ICD-10, will create additional stress (economic, financial, and mental), especially for intermediate and small physician practices.
The World Health Organization (WHO) plans to release the ICD-11 classification somewhere between 2015 and 2017 (depending on which WHO document you read). Not only will ICD-11 incorporate all the functionality of ICD-10, it will be digital only (no paper manuals) and will link with terminologies such as SNOMED CT (Systematized Nomenclature of Medicine – Clinical Terms) and support electronic health records and information systems. Remember that a WHO “release” as early as 2015 still means that various agencies and committees will have to meet and develop the Clinical Modification (CM) that will be used in the U.S.
ACCCBuzz: Any parting advice?
Parman: Use any implementation time resulting from a delay in ICD-10 transition to improve operations, documentation integrity, and coding skills. Never waste the gift of time!
Editor’s Note: ICD-11 release date in this post was updated 4/14/14 to reflect ambiguity in the current WHO timeline.
By Sydney Abbott, JD, Manager, Public Policy & Provider Economics, ACCC
For nearly 30 years, researchers, physicians, and cancer patients have relied on clinical trials provided by the National Cancer Institute’s (NCI’s) Community Clinical Oncology Program (CCOP). Now, due to the Congressional budget-reduction mindset, NCI is woefully underfunded, leading to the Institute’s decision to end funding for federally-funded clinical trials through CCOP as of June 1, 2014. The NCI CCOPs bring clinical trials to patients in their local communities across the country and support for these could end until new NCI research grants are awarded in September 2014, at the earliest.
Additionally, NCI’s new National Clinical Trials Network (NCTN) is facing a 40 percent budget reduction, which has led to a reorganization of cancer clinical trials, including fewer investigators and a total reduction in number and size of trials funded.
The primary programs in the NCTN, CCOP, the Minority-based Community Clinical Oncology Program (MB-CCOP), and the NCI Community Cancer Centers Program (NCCCP) will be consolidated into the NCI Community Oncology Research Program (NCORP). As announced by NCI on April 4, “NCORP will be comprised of some of the sites formerly funded through the CCOPs, MB-CCOPs, and NCCCP…” [emphasis added]. Please see the NCI statement here.
ACCC is concerned that a reduction in clinical trials will lead to decreased innovation of cancer therapies, as well as decreased access to the best care for cancer patients. ACCC urges NCI to reinstate funding for the CCOP and to continue support for community-based clinical trials and research.
Editor’s Note: Since this blog was posted, NCI has issued a letter clarifying funding for community clinical trials during the transition to the new NCORP. Read our update blog here.
With polarization on Capitol Hill impeding the legislative process, ACCC 40th Annual National Meeting keynote speaker Kavita Patel, MD, of the Brookings Institution told attendees: “If you are looking for change, I would point you to your own selves in the mirror, not to Washington, D.C.”
With the Senate having passed the SGR reform patch the night before, Patel noted that despite the fact that SGR reform was one of the few things with bi-cameral support in Congress, ultimately, we once again have a one-year “doc fix.” This is the 17th time Congress has enacted an SGR patch since the formula went into effect in 2002.
Still, Patel believes there is potential for Congress to act on long-term reform next year.
The current “SGR fix” legislation reflects Congress’s focus on “value” and value-based alternative payment models, she noted.
“At some point, it will be important for your community to think about what that would look like at your programs.” She believes medical oncology may be well suited to what Congress is thinking about with alternative payment models.
While cancer care has evolved so greatly over the past several decades, our reimbursement policies to pay for that care have not evolved.
Among the alternative payment models, Patel believes the medical home model may be suited to oncology, while bundling is a poor fit.
“If people think there’s going to be bundling in oncology, they are wrong,” she said.
So is fee for service gone forever? “No,” says Patel. “The answer is there is always going to be room for fee for service in certain settings.”
But, some form of risk-sharing is definitely in the cards. “In 10 to 15 years, the majority of people in this room will have some sort of risk-based contract…that will become the norm in the next several decades.”
However, she warned that if you turn to Congress for a solution, they are likely to turn it around and ask you to show them viable solutions—and this is a good thing.
At the end of the day, I think we need more clinical voices in the policy setting arena, “ she said. “You don’t want Medicare or Congress thinking about cancer care without [our] voices.”
by Sydney Abbott, JD, Manager, Provider Economics & Public Policy, ACCC
ACCC’s Capitol Hill Day on March 31 is less than one week away. ACCCBuzz is featuring a primer series on the key issues ACCC members will be talking about on Capitol Hill. In this third of four installments, we’ll look at the need to pass federal oral parity legislation.
By now you know the issue: oral parity legislation is needed to ensure that patients can afford their oral anti-cancer medications. And you have probably already heard that 29 states have passed oral parity laws requiring insurance companies to cover oral chemotherapies at the same rate they already cover IV-infused medications. Considering that more than half of the states have passed oral parity laws, and that number continues to grow, why is oral parity an advocacy issue for ACCC’s federal Hill Day?
Even though state laws are currently being passed, federal legislation is still required for two important reasons:
- Language of the laws varies across the states and only federal legislation will ensure the same protections for all patients; and
- State laws only impact state-regulated plans. Federal legislation is needed to cover self-insured plans (ERISA).
Currently, there are bills in both chambers of Congress, just waiting for ACCC advocates to push them forward. HR 1801 in the House has 71 cosponsors, while the newer S 1879 in the Senate only has one cosponsor. ACCC members, please speak up for this important legislation.
Those of you coming to Washington, D.C., on March 31st for ACCC’s Hill Day will have a chance to explain why this legislation matters in person.
ACCC members who cannot make the trip to D.C. next week can still express support for federal oral parity legislation and ask Congress to pass HR 1801 and S 1879. Visit ACCC’s Legislation Action Center to find out how.
by Sydney Abbott, JD, Manager, Provider Economics & Public Policy, ACCC
Just 12 days remain until ACCC’s Capitol Hill Day on March 31. ACCCBuzz is featuring a primer series on the key issues ACCC members will be talking about when they visit their elected officials. In this second of four installments, we’ll look at the sequester and legislation to exempt cancer drugs from the cuts.
As you already know, the sequester was put into effect as a result of failed debt negotiations in Congress in 2011. Initially, the sequester was designed to impact all domestic spending equally for 10 years. However, through the budget deal at the end of 2013, pre-sequester funding was restored to some federal agencies, while being extended for other programs. Medicare was one of those unfortunate programs. Instead of ending in 2021, the 2% across-the-board sequester on Medicare has been extended through 2023.
Considering this extension, ACCC has shifted focus from eliminating the sequester altogether to exempting cancer drugs specifically. There is currently a bill in the House that would leave the sequester intact for all items billed to Medicare except for cancer drugs. Because of the high fixed costs of cancer drugs, the sequester disproportionately impacts oncology. However, HR 1416, with 110 bipartisan cosponsors, would help level the playing field between oncology and other specialties.
By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
In a recent blog, we raised concerns about the slippery slope of CMS’s proposed sweeping changes to the Medicare Part D Program, including a proposal to eliminate at least two of the six protected classes of drugs. ACCC submitted comments, coalesced with 371 organizations to send a letter urging withdrawal of the proposal, and supported the Senate Finance Committee’s request to avoid changes to this already successful program.
ACCC is proud to announce that, thanks to the voices of our members and the work of related organizations, CMS Administrator Marilyn Tavenner has announced that the agency will not be moving forward with four of the proposed changes to the Part D Program, including the proposal related to the “protected classes” definition of three drug classes.
On behalf of Medicare beneficiaries, we thank Administrator Tavenner for this sound decision.
By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
We’re on the countdown to ACCC’s Capitol Hill Day on March 31. ACCC members who join us will be visiting with congressional staff to speak out on major concerns affecting oncology care. Those on the front lines of cancer care can deliver a powerful, clear message on issues affecting cancer patients and providers. Patient access to care—in particular to anti-cancer medications—is a cross-cutting concern.
Where Things Stand in Congress—Two Bills
Many health insurance plans cover IV chemotherapy, injected anti-cancer medications, and oral anti-cancer drugs differently, causing patients to pay far more out-of-pocket for oral drugs than for IV chemotherapy or injected medications. With the ever rising cost of healthcare, insurers employ various methods to keep costs down, including increasingly shifting the cost of prescription drugs to patients. To help patients afford the life-saving medications they need, Congress has introduced two complementary—if not somewhat confusing—pieces of legislation: HR 1801 and companion bill S 1879 to lower the cost of prescription oral chemotherapy drugs, and HR 460, to limit cost-sharing requirements for prescription drugs on specialty tiers. Both bills aim to protect cancer patients in different ways.
Here’s a quick side-by-side comparison of the legislation. For ACCC members joining us for Capitol Hill Day, this snapshot can help you prepare for conversations with congressional staff.
Oral Parity (HR 1801/S 1879)
- Legislation would require insurers to provide coverage for orally administered anti-cancer medication under terms no less favorable than for medication administered intravenously. Insurers may not create parity by raising rates for IV infusions.
- Focus is on cost-sharing across prescription drug coverage and office visit coverage for anti-cancer medications only.
- Requirements: A physician must deem the treatment to be medically necessary for treating cancer, and the treatment must be clinically appropriate in terms of type, frequency, and duration.
- Types of insurance affected: Group and individual private plans and self-insured group plans regulated by ERISA that cover oral and IV-infused anti-cancer medications.
Specialty Tier (HR 460)
- Legislation would limit cost-sharing requirements applicable to prescription drugs in a specialty tier to the dollar amount of such requirements applicable to prescription drugs in a non-preferred tier.
- Focus is on cost-sharing in prescription drug coverage plans and formularies for any specialty-tier drug covered by the plan.
- Requirements: A health plan that provides coverage for prescription drugs using a cost-sharing structure shall not impose cost-sharing requirements applicable to prescription drugs in a specialty drug tier that exceed the dollar amount of cost sharing for drugs in a non-preferred brand tier.
- Types of insurance affected: Group and individual private plans that cover prescription drugs and use a formulary or other tiered cost-sharing structure. Bill language is unclear as to whether ERISA plans are affected.
Both bills help protect patient access to affordable prescription drugs. However, because oral parity legislation already has 67 co-sponsors in the House and a companion bill in the Senate, this will most likely move through Congress first. Therefore, ACCC will be advocating for oral parity (HR 1801/S 1879) in both chambers on Hill Day. In addition, we will be talking to our representatives about SGR reform, elimination of cancer drugs from the 2% Medicare sequester, and elimination of the prompt pay discount. Learn more about Hill Day 2014 and register today.
by Amanda Patton, Manager, Communications, ACCC
This week Health Affairs announced its 15 most-read articles of 2013. Topping the list: “What It Will Take to Achieve the As-Yet-Unfulfilled Promises of Health Information Technology” (January 2013). Authors Arthur Kellermann and Spencer Jones of the RAND Corporation re-visit a 2005 Health Affairs article from a team of RAND researchers that projected savings of more than $81 billion annually from rapid adoption of health information technology.
Seven years down the road—the picture is not so bright. Kellerman and Jones report that data show health IT’s impact on healthcare efficiency and safety is mixed and, meanwhile, annual expenditures on healthcare in the U.S. have grown by $800 billion. The authors cite a number of hurdles impeding progress toward realizing health IT’s full promise. These include selection of systems that lack interoperability and are not easy to use, along with failure on the part of providers and healthcare systems to re-engineer care processes to fully take advantage of the benefits of health IT.
Still, the authors are optimistic that the original promise of health IT can be realized. However, they say for this to happen we need standardized, easy to use systems; more interoperability; increased patient control of their healthcare information; and providers to re-engineer their care processes to fully benefit from the efficiencies offered by health IT.
Health Affairs is offering free access to all of its top 15 articles until January 28.
On the theme of the yet-to-be-realized potential of health IT, ACCC’s white paper Cancer Care in the Age of Electronic Health Information Exchange offers oncology-specific perspective on adoption and integration of health information exchanges (HIEs), a key component of health IT. Developed through ACCC’s Institute for the Future of Oncology, the paper reflects a forum discussion of current barriers and successes in adoption of HIE. Among the key findings:
- HIE adoption is uneven. Despite the potential that HIEs have to improve patient care, reduce redundancies, lower costs, and demonstrate quality—for example, by allowing participating providers to benchmark interventions within their own patient populations—the oncology community is experiencing patchy adoption and implementation, with the potential being realized in some areas but not others.
- There is lack of awareness around HIEs. There are many known benefits to participation in an HIE, but information about these benefits needs to be more widely disseminated.
- HIE initiatives must focus on information standardization, so that data can be easily exchanged by providers and viewed by patients.
- Challenges remain as to how to achieve interoperability so that data can be exchanged seamlessly across large geographic areas while best ensuring privacy and security.
- Providers must have input on the information released via patient portals. Patient portals can contribute to patient empowerment, but protocols must be put in place so that providers have input on the information released and the timing of that release, and have the opportunity to answer patient questions.
It’s no surprise that many of the issues identified in ACCC’s white paper—the need for standardization, interoperability, ease of use, and provider involvement in health IT processes—resonate with the findings of Kellerman and Jones. While remaining optimistic, there is consensus that much work remains to be done.