Evidence-Based Oncology

Challenges in Oncology Practice | Page 2

Published Online: October 23, 2013
A Discussion With Anupama Kurup Acheson, MD, 2013-2014 Chair of the ASCO Clinical Practice Committee
In the past 2 or 3 years we’ve been seeing a lot more consolidation as doctors transition out of community practice. One of the prime drivers of the recent census was to get a better handle on this trend, and from last year’s survey (http://bit.ly/asco_survey) we saw considerable movement. We’re seeing a lot of mergers, especially in metropolitan areas. Larger practices reported plans to purchase smaller ones, while smaller ones said they were more likely to close. Again, the sequester is having an impact. In order to survive in this environment, solo practices are paying close attention to information provided to them by community oncology consortiums on how practices across the country are coping. They are able to manage some costs by joining together;

group purchasing for drugs is an example.In terms of providing multidisciplinary care, independent practices recognize the value of interacting with specialty providers given the complexity of disease, and while this takes more time, they see it as a necessity. What sort of momentum is there behind new care delivery models such as patient-centered medical homes (PCMHs) and accountable care organizations (ACOs)?

Over the past few years, there has been a lot of talk about developing new models and growing calls for more pilot testing, with the understanding that these new models would require a wholesale change in how we practice medicine. In cancer care, however, it’s important to keep in mind that a onesize-fits-all approach will not work. ASCO would look for a menu of options:

different types of models that will support the level of care we need to provide. In the near-term, we’re looking for more pilot testing of clinical pathways to guide evidence-based care and patient-centered medical homes. However, we recognize that these models may make sense in some parts of the country and not in others. These pilots, which require a significant commitment of time and resources on the part of practices, are still in the early stages. But we are very encouraged. Going forward, we need to make sure the menu is developed thoughtfully and that we put in place a transition period so that we can fully assess how they are working. In general, oncologists must continue to tie the work they do to what’s important to patients. We need to be

more careful about utilization of tests and services, making sure that whatever we order is meaningful. A lot of positives will come out of this.

What’s happening on the payment reform front?

As the Medicare population grows, reimbursements for services are not keeping up with cost increases and we are bearing a large part of the added cost. So we are very encouraged at ASCO to see an appetite in Congress to reform unworkable aspects of the current payment system, including the SGR model and the fee-for-service system, which requires a wholesale change. Importantly, more elected representatives are reaching out to us for feedback, asking for our ideas about alternatives to SGR, for example. And we are putting pen to paper.

ASCO’s Payment Reform working group is examining proposals for different payment models. We’ve developed a set of principles, which we believe should underpin any new payment system. We believe any new payment system should be tied to quality improvement, be physician-led, not add to the deficit, and provide a transition period to allow for additional testing. The House Energy and Commerce Committee has asked ASCO to provide feedback on its draft legislation. We’ve been supportive of the legislative proposals that encourage all specialty physicians to participate in a quality assessment and clinical improvement program. Patient outcomes, with quality as the underlying goal, must drive these changes. To ensure value, physicians must make sure that the services we provide are clinically meaningful. The challenge is that there is so much variance among patients that care must be tailored accordingly. Also, these new models must work in relation to private payers; care has to be consistent across the patient population. But we do find that private insurers are interested in clinical pathways.

What is the impact on practices of new drug approval processes, including the FDA’s accelerated approval pathways? Are there increased responsibilities and risks as a result of these changes?

It’s very encouraging that the FDA is using regulatory flexibility to speed up the approval process for breakthrough therapies for life-threatening diseases. ASCO supports this and has worked closely, for example, with the agency’s Office of Hematology and Oncology Products to host workshops to advance surrogate end points for use in specific cancer types to enable use of the accelerated approval mechanism. In each case, how quickly these drugs are approved depends on the data and how easy they are to collect. The FDA has demonstrated the ability to approve agents on the basis of trials that involve a relatively small number of participants. This translates to earlier access to the agents, but this does place the responsibility on us as clinicians to closely monitor patients for unexpected side effects and on organizations like ASCO to advise our members that they may have to change treatment plans if there are adverse effects or drugs are not working. We also need to keep a close eye on information from clinical trials, understanding that use of agents in this setting is experimental, even if the agent is already approved for a different indication.  Particularly in the case of agents approved via the accelerated approval mechanism, the approval is granted on the basis of a surrogate end point that is reasonably likely to predict clinical benefit. We need to stay in touch with confirmatory studies and data from these trials to understand whether the agent meets the clinical benefit expectation.

Are independent oncologists enrolling their patients in clinical trials? What are the practice implications?

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