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Evidence-Based Oncology Patient-Centered Oncology Care 2015

ASCO President Reviews Post-SGR Challenges for Oncologists

Surabhi Dangi-Garimella, PhD
Keynote speaker Dr Julie Vose said the oncologist faces many administrative burdens in the transition to value-based care. Solving them is essential to spending more time with the patient.
At Patient-Centered Oncology Care 2015, hosted by The American Jour­nal of Managed Care in Baltimore, Maryland, keynote speaker Julie M. Vose, MD, MBA, FASCO, president of the Ameri­can Society of Clinical Oncology (ASCO) provided perspectives on the challenges faced by oncologists as the healthcare system transitions to define and incorpo­rate value in the care delivered.
 
“Unfortunately, there is an adminis­trative burden that physicians have to bear and so there’s not much time to spend with the patient,” she said, add­ing, “We have to take this back to the pa­tient and physicians need to ensure that they don’t just turn into data-entry op­erators,” hinting at the growing adminis­trative burden faced by physicians.
 
Achieving the triple aim of better care, improved heath, and lower costs—all in a value-based manner—are a physi­cian’s goals, “But how do we get there?” asked Vose. She indicated that the an­swer is enveloped in multiple layers:
• We need to make sure evidence-based practices are followed
• Available resources should be used efficiently
• Quality measures and improvement are vital
• Practices need adequate support to avoid duplication of efforts and im­prove patient engagement, in order to provide better care in a value-based manner
• Oncology is based on innovation and new treatments should be val­ue-based.
 
Pointing to CMS’ em­phasis on transitioning from the fee-for-service (FFS) to value-based care, Vose said that FFS drives volume without neces­sarily ensuring quality. “The administration has set an ambitious goal of at least 50% of all Medi­care payments based on alternative payment models by 2018. I don’t think this is pos­sible by 2018 though,” she said.
 
Vose emphasized that patient care should achieve the highest value level. “Cost and toxicity should be incorpo­rated into the value proposition and we need to move beyond process mea­sures and ensure outcomes improve with the value-based changes,” she added (FIGURE 1).
 
Most quality measures today are pro­cess-based, said Vose, and pointed to ASCO’s QOPI project (Quality Oncology Practice Initiative) that allows for per­formance measurement and feedback. In addition to process measures, QOPI site visits ensure meeting QOPI certi­fication. Additionally, mentorship pro­grams allow data exchange and further help dissipate the model, she said.
 
How has ASCO improved on these es­sential requirements?
It’s been a multi-pronged approach through the efficient use of Choosing Wisely; PracticeNet, a suite of services to allow value-based care and improve clinic practices; and team-based care, which is extremely important, especial­ly with the increased need for oncolo­gists as the rate of patients with cancer rises.
 
Vose then explained that ASCO’s Val­ue Framework has tried to incorporate all of these factors: shared decision-making, added benefit vs existing thera­py, meeting individual patient goals and circumstances.
 
She talked about the Merit-Based In­centive Payment System (MIPS), which came into being after Medicare Authori­zation and CHIP Reauthorization Act or MACRA replaced the Sustainable Growth Rate (SGR), a big step forward, but, thus, has created new needs. This would bring about a significant change and create a big opportunity to improve patient care. Physicians can use MIPs or alternative payment models—a new way to look at performance measurement. However, public reporting that pits physicians against one another represents a big change, and it will take time to adapt.
 
“Although the SGR is gone, we are still cutting up one pie. The size of positive updates or bo­nuses depends on how many people get penal­ties for not performing. This is new. And scary,” Vose added.
 
MIPS will significantly impact the physician payment program in terms of dollar cost, she said, in primarily 4 do­mains: resource use, quality reporting, HER, and clinical improvement activi­ties. “The information will be collected, beginning 2017, to be implemented in 2019. We need tools to help with gap in care coordination that don’t currently exist,” Vose added.
 
Oncologists, though, are feeling un­prepared. “While the goals providers have been striving to meet are still the same, such as meeting national bench­marks for quality in the form of perfor­mance measures, making use of EHRs, continually improving our clinical care, and doing it in the most efficient way possible, challenges remain.” Measure­ment tools remain the major challenge.
 
“And MACRA comes at a time when there is already significant turbulence in the oncology practice community,” Vose emphasized.
 
Oncologists face a lot of practice pres­sures, and they vary based on physician-owned community practices, academic, or health centers, (FIGURE 2). “Smaller practices are our special concern; they are the backbone of the US oncology care delivery system. But the current trend is toward consolidation, which is modifying the face of oncology.”
 
Information overload is not helping oncologists either, whether it be clini­cal information or administrative ad­aptations with new rulings and require­ments. “There are also administrative overloads; we know of a practice that had 8 different clinical pathways for each of the payers they worked with.”
 
Indicating that APMs can help achieve transformation, Vose said that ASCO’s patient-centered oncology payment model tries to match support with the work being done to avoid cost-shifting to patients. “It’s a big collaborative proj­ect and we plan to data-share to get feedback for improvement,” Vose said.
 
How do we agree on improving on pathways and value measures?
While rapid-learning systems would improve efficiency of care, there are challenges that need to be met:
1. Need new ways to test drugs per tu­mor’s molecular characteristics, eg, NCI-MATCH, TAPUR
2. Learn from every patient (irrespec­tive of trial participation)
3. Harness data in powerful new ways.

“The patient needs to be the center of what we are doing: improve outcomes, reduce side effects and do this in a val­ue-based manner. We need to harness our collective wisdom as we do this,” Vose said.
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