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Conference Coverage: COA
Surabhi Dangi-Garimella, PhD
AJMCtv® Interviews, June 2017
Produced by Laura Joszt

Conference Coverage: COA

Surabhi Dangi-Garimella, PhD
A rundown of sessions at The Community Oncology Alliance (COA) annual meeting, held April 27-28, 2017, near Washington DC. This year’s theme was Fueling the Cancer Moonshot.
Oncologists Believe Achieving Cancer Moonshot Goals Should Start in the Community

Former Vice President Joe Biden's Cancer Moonshot initiative1 placed significant emphasis on the role of cancer centers in improving the nature of oncology care delivery in the country, ultimately to improve patient outcomes. However, community oncologists believe that they are in a very good position to lead the way.

Joining this discussion at the 2017 Community Oncology Conference, April 27-28, in National Harbor, Maryland, were William Harwin, MD, president and managing partner, Florida Cancer Specialists; Edward Licitra, MD, PhD, chief financial officer and director of revenue cycle, Central Jersey Division, Regional Cancer Care Associates (RCCA); and R. Steven Paulson, MD, President, Texas Oncology. Debra Patt, MD, MPH, MBA, vice president, Texas Oncology, moderated the discussion.

When asked about the role played by each of the practices in fueling Cancer Moonshot, Harwin said that many different factors can influence Cancer Moonshot, including developing a patient care system. “We have about 50 patient managers, many of whom work remotely,” he described. “We also have an active phase I unit on site, and that’s one of our biggest initiatives.”

As a result of requirements of the Oncology Care Model (OCM),2 Harwin’s organization also has a care management team. “They are available 24 hours and provide triage, which is very valuable for our patients,” he said. The team members, Harwin added, adhere to protocols developed for triage management and psychosocial support.

Paulson noted, however, that the challenge with OCM is the upfront investment for additional staffing, to ensure that reporting requirements and change implementation can be met. Paulson also addressed the importance of extending clinic hours to avoid emergency room visits.

“OCM has given us the ability to focus and change culture,” Licitra emphasized. He explained that the changes that a practice infuses to meet OCM requirements are not restricted to Medicare patients; they extend to other patient populations as well. “While it is a work in progress, we are trying to centralize our processes,” he said, adding that RCCA is working with Innovative Oncology Business Solutions, co-founded by Barbara McAneny, MD, to bring this about.

“How important is research for your practice and how have you built it into your practice?” Patt asked the panelists. Licitra noted the importance of data integration to improve patient outcomes. RCCA is assembling all the genomics and proteomics information on patients and then trying to identify ways to improve outcomes. “We are using tools to understand both clinical and financial outcomes,” he added. “We need people to realize the value of community oncology and they come to us and give us the opportunity to care for them,” Licitra said.

Paulson explained that Texas Oncology has built relations with hospitals, clinics, and the pharmaceutical industry to help support their in-house research efforts. “We try to create a situation where the best molecules are accessible to our patients,” he said. He is, however, concerned with the low rate of clinical trial enrollment, especially among newly diagnosed patients.

Challenges to Delivering Research in the Community Setting

Patt indicated that in addition to operational costs, individual clinicians contributing time presents challenges. “What are the other challenges that you face and how can they be overcome to facilitate research in the community clinic?” she asked.

Harwin said that his practice uses a clinical trial navigator, and it also employs Flatiron Health’s OncoAnalytics platform.3 “But we cannot replace physicians,” Harwin said, emphasizing the need to raise awareness through fellowship programs.

“Patient identification and physician engagement are key,” said Licitra, indicating that modifying physician compensation models can have a significant impact. Paulson agreed with Licitra. “You can change reimbursement models to include financial incentives for participating in clinical trials,” he said, noting that community clinics should work towards the goal of providing patients access to a research platform.

Clinical trials enable huge savings because you don’t have to pay for the drugs, Harwin said. To ensure timeliness of acquiring information, “We have our own molecular testing facility,” Paulson said. It helps the clinic, too, to better aggregate the patient’s molecular data along with clinical information. “We have also created an outpatient interventional radiology facility, which costs half of what we would pay for if the patient goes to a hospital,” he added.

Patt noted the importance of clinical decision support, which allows quality improvement, faster treatment by helping with prior authorization, and better outcomes. She also emphasized the importance of telehealth for practices with multiple sites. “We can’t have every expert at every site of care, and we need to identify ways to bridge geographical gaps,” she explained, adding that telehealth services need to grow quickly “because we may not provide all services at every site across large practices.”

Licitra believes that curing cancer and curing the cancer care delivery systems are the targets of reimbursement models, and they are both significant challenges. However, Paulson said that even if doctors do not like these changes, it is important to climb on board since the OCM is fueling the opportunity to bring about changes.

Pratt noted the importance of community oncologists “telling their story.” “We need to allocate more time to this,” she said.


1. Dangi-Garimella S. The fate of Cancer Moonshot in 2017. The American Journal of Managed Care® website. http:// Published November 11, 2016. Accessed April 28, 2017.

2. Dangi-Garimella S. Will a payer-provider collaboration guarantee OCM success? Am J Manag Care. 2016;20(SP16):SP616-SP617.

3. Dangi-Garimella S. Flatiron’s EHR platform for OCM participants promises to foster value-based care. The American Journal of Managed Care® website. to-foster-value-based-care. Published July 28, 2016. Accessed April 28, 2017.

Linking Claims, Clinical Data Is Essential for a Learning Health System

“Big data” is a term used as commonly as the term “value” in cancer care. However, similar to value, the interpretation of big data can vary, according to Robert Green, MD, vice president of clinical strategy and senior medical director at Flatiron Health. Is the rubber meeting the road with big data in cancer care? “No … rather, not yet,” Green said at the 2017 Community Oncology Conference, held April 26-27 in National Harbor, Maryland.

Green explained that in order to make data from electronic health records useful, real-world quality data play an important role. However, it is also important to link clinical and claims data. “That’s where the future is,” he said.

Quoting quantitative scientist Gary King, PhD, from Harvard University, who said, “Big data is not about the data,” Green explained that it’s about using the data to generate meaningful insights. “At Flatiron, we define big data based on its complexity, rather than the volume.”

The focus should be on leveraging the data for high-value care, on improving outcomes, and accelerating clinical work, Green explained.

“We are being asked to develop interventions that will affect care and the financial viability of our practices,” he said. “To achieve this, we need to feed all this information back into our system to improve work flow…the concept of a learning system.”

He believes that processing structured data is key to be able to use these data, often described as “data scrubbing.” But a lot of information is not structured—such as pathology or physician notes—and a method needs to exist to extract this information.

“Unstructured data are typically hard to get at, and it’s not possible to get these data into a structured form, accurately, and use them to generate feedback and improve care,” he said.

Green told the audience, most of whom were oncology care providers, that although most providers think they are good at what they do for patients, “I don’t believe the metrics that I am reporting on are really bringing value to the patient because I checked the required box, such as measuring pain medication.” So, he asked, how do providers find out if they are taking good care of their patients?

“You don’t know how well your patients are doing unless you try to measure their performance,” Green said, and he outlined what is needed to generate real- world quality data:

Fill in the gaps. He stressed that filling in data gaps is very important to be able to mine high-quality data, and this means combining unstructured data with raw structured data.
Identify cohorts. Identify the appropriate patient cohort on which to conduct analyses. Defining the cohort is important when measuring quality to report on metrics.
Develop an analysis plan. Develop, document, and apply a rigorous plan. It is easy to miss the right answer if the data are not thoroughly evaluated, he said.

Case study 1. Green then provided a case study on assessing clinic adherence to EGFR and ALK testing in non–small-cell lung cancer (NSCLC). Analysis of Flatiron’s database found that only 21% of patients were tested across the network of practices that were conducting this genetic test.

“But when we drilled down even more, the median testing rate was 16%—some clinics were testing 100% while others were only testing infrequently,” he said.

So there was significant variance across clinics, which was apparent only when Flatiron analyzed the data at the individual clinic level.

Case study 2. Green showed that in their 2012-2014 data set, KRAS testing rates for colorectal cancer were 71% in 2012 and then just 57% in 2014. The variability was 90% to 35% across 21 clinics, and testing rates rose with later lines of therapy: 62% at first-line and 90% by third-line and above.

“Such detailed information can influence how we collect, analyze, and report on quality metrics and how it ultimately affects reimbursement in that practice,” Green said.

To highlight the importance of linking clinical and claims data, Green compared the value that claims data bring to quality analysis, and he also noted specific challenges. While claims data do provide insight into the total cost by disease type, and help identify cost drivers, drug compliance rates, and information on hospitalization and emergency department visits, that information is not sufficient, Green said. Claims data, he added, lack attribution and don’t have enough clinical depth to have a real influence on cost.

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