Shift in Site of Care, Real or Fiction?

Posted in ACCC News, Cancer Care, Healthcare Reform by ACCCBuzz on April 17, 2013

by Amanda Patton, ACCC Communications

2013 Town Hall 13

One way to ensure a place at the table? Invite everyone to lunch. On March 8 the Association of Community Cancer Centers (ACCC) did exactly that with its lunchtime Town Hall Meeting “Shift in Site of Care, Real or Fiction?” during the ACCC 39th Annual National Meeting.

Moderator William T. McGivney, PhD, asked panelists Christian Downs, JD, MHA, ACCC Executive Director; Joseph Bailes, MD, FACP, healthcare policy expert; and Eli Lilly & Company’s Byran Litton, MBA, to explore issues around the shift in site of care and its implications, as well as the move away from fee-for-service reimbursement to shared-risk models such as bundled payments, episode-based payments, and ACOs. Here’s what the panel had to say.

Shift in site of care—it’s real and it’s already underway.  

Citing ACCC’s Cancer Care Trends Survey, now in its fourth year, Downs noted the continuing trend of office-based physicians looking at creating arrangements with hospitals.  The answer to why this is happening and what this shift will mean for cancer care is complicated, requiring a multifactoral analysis, Downs said. However, two forces are clearly at work: financial pressures and a demographic shift.

Well-known financial pressures squeezing physician practices include increasingly expensive anticancer therapies, more patients who are uninsured and underinsured, and rising patient copays. With reimbursement decreasing in the physician office setting, there’s a sense that joining forces with the hospital may provide opportunities to continue to provide community-based care in the physician office.

Another driver of change is a demographic trend in favor of employment, Downs said. Younger healthcare providers, in general, are comfortable with hospital employment.  This is a different scenario from 10-15 years ago, when providers seemed to have more entrepreneurial interest in establishing their own practices.

It’s not déjà vu all over again.

Although the healthcare community did go through a similar shift in the 1990s, what’s happening today is a little different, commented Bailes. “For the medical oncology community, I think [the shift in site of service] is an opportunity to look at innovative partnerships. I think it’s going to be accelerated by ACOs to a certain extent.”   Currently there are about 300 approved ACOs, and many of these are hospital-centric systems, Bailes pointed out. “…I think it’s going to be incumbent on the oncology community to be part of this hospital-centric approach.”

It’s too soon to know exactly how this shift will impact cancer care.

“I think the trend started [over] the last several years for many reasons…and we don’t know the end result,” Bailes said. What he has heard consistently from medical oncologists is that they want to do the right thing for the patient and ensure that an individual with cancer can get access to new therapies that are being developed.

Downs echoed that sentiment, adding that at this stage, it’s important to be wary of broad generalizations about the “best” practice environment. “It’s got to be a case-by-case analysis,” he said. In some locations partnering with a hospital will work, in other locations it may not.  Much depends on the specifics of the community.

Protecting the cancer care delivery infrastructure in this time of flux is critical.

Downs pointed out that the cancer care delivery infrastructure is “very fragile fabric. If we pull too hard on one string, it could unravel.” He emphasized the importance of looking at the factors in each community. Bailes concurred. “It’s going to be an individualized decision.”

One area in which the oncology community has done a good job is laying the groundwork for discussion with both policymakers and payers. Despite this, “it’s a big challenge,” Downs said. “Policymakers look to us for answers. I don’t know if the answers are ripe yet. We know we want to end up doing what is best for the patient and the provider.”

It’s important to reserve a patient’s ability to choose.

From the industry perspective, rather than choosing sides—hospital vs. practice—“We really want to reserve choice in site of care for the patient,” said Litton. “Whatever’s best for that patient and that community, we want to support.”

Along with the shift in site of service is the trend away from fee-for-service toward risk-based models.

What are the implications of this move toward increased risk-bearing for physicians and hospital groups? For providers bearing risk is complicated, Downs pointed out.  From a business standpoint, few providers may find it worthwhile to adopt this model.

Panelists agreed that while some markets might be appropriate for risk models, others would not be a good fit.

In some communities a risk model may not be the best use of resources that could be otherwise employed to improve care in the community, Litton said.

Downs also drew a distinction between risk-bearing models and bundled payments. “As we start to see some of this shift in site of service, hospitals may be a little more comfortable with bundled payments than practices,” he said.

For hospitals to be able to engage in bundled payments or episode-based payments, they’ve got to be able to understand and define the resources used, McGivney added. This means facilities must have the infrastructure in place to do this.

He noted that more than 500 participants—not-for-profits, for profits, practices, academic programs, etc.—have signed up for CMS’s recently announced bundled payment initiative that includes 48 different areas. (However, most are related to orthopedics, with only one area related to oncology.)

Oncology doesn’t lend itself to bundling; the odds of bundled payments becoming common in oncology are low.

While CMS has looked at creating a bundled payment for oncology, the archetypes for bundling have been around procedures and it’s difficult to establish a defined set of resources for oncology.  Cancer care involves stages, variances related to co-morbidities, different lines of therapy, etc., and that makes bundled payment a difficult fit.

Oncology is clinical trial driven. The rapidity of change in oncology and the rapidity of new drugs makes it difficult to set bundled payments that will last a decade and provide economic predictability, noted Bailes. “That’s one of the challenges being faced by Medicare. From a fiscal side…to provide economic predictability over a decade…you can’t do that if you have to make a bundled payment with no provision or separate payment for new technology.”

New technology carve outs are necessary to protect innovation.

Molecular testing is a prime example of the importance of new technology in oncology and the accompanying challenges innovation brings. “They [new molecular diagnostic tests] are going to be sophisticated diagnostics that will [need to] have a more sophisticated reimbursement associated with them,” Bailes said.

Bringing the discussion back to the current oncology environment, McGivney asked each panelist to conclude by citing one event or policy that they would like to see happen that would have a real-world impact on cancer care in the next year.

Downs:  “I’d like to see us do a better job of educating our patients on the financial responsibilities for their cancer care. Right now—not just [for] our uninsured and underinsured—even for patients with good insurance policies, I don’t think we do the best job of explaining what [these costs] will mean.”

Bailes: “Congress should streamline the FDA regulatory process and get drugs to the patients [faster], because we are trying to turn cancer into a disease that’s treatable and lets people live long and active lives.”

Litton: “Only 3 to 5 percent of oncology patients go on clinical trials, and I think it’s a black mark on the legacy for anyone in the decision-making seat in oncology. We’re too siloed [in terms of the drug development process]… if we could go from 10 to 15 years and $1 billion to develop a drug to 4, 5, or 6 years [and] $400 million to develop a drug—that changes our ability to invest more deeply. It changes our pricing structure. It brings innovation to patients faster.”

For all panelists the bottom line is making sure patients have access to quality care.

*This program was supported by PACE.

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