Coverage from the Community Oncology Alliance 2022 Community Oncology Conference, held March 17-18 in Kissimmee, Florida.
From Getting Paid to Managing Burnout, Panel Examines Future of Community Oncology Care
Value-based oncology care is here to stay, with or without leadership from CMS, because commercial payers and patients have seen its benefits, according to leading practice administrators who took part in the March 17 discussion, “Building/Designing the Community Oncology Practice of the Future,” during the 2022 Community Oncology Conference, presented by the Community Oncology Alliance.
Barry Russo, MBA, CEO of the Center for Cancer and Blood Disorders, moderated the session, which featured Glenn Balasky, executive director of Rocky Mountain Cancer Centers; Jeff Vacirca, MD, CEO of New York Cancer & Blood Specialists; and Emily Touloukian, DO, president of Coastal Cancer Center.
Russo asked for predictions on the future of reimbursement, and Balasky said CMS’ decision to let the Oncology Care Model (OCM) expire without a replacement will create “an awkward transition,” because the OCM helped propel movement away from fee-for-service (FFS) reimbursement.
“I see a future where the private payers want the benefits of value-based care,” Balasky said. After years of experimentation with the OCM, some payers were taking steps such as paying for advanced care planning. Data collection from OCM patients will help practices show payers how value-based care worked in their favor, he said.
The challenge now will be finding ways to retain momentum. “We’ve got to keep on this path,” Balasky added.
Vacirca said the next step is to work with employers to demand movement away from FFS toward payment for episodes of care. Among insured patients in New York, he said, 90% are dealing with a payer that is a third-party administrator (TPA) of their plan—and in these cases, there’s no incentive to cut premiums.
“If they drive premiums down as the TPA, they make less money,” Vacirca said. “You’ve got to get to the employers, because the employers have no clue whatsoever that the payers are working contrary to what are their best choices.”
Together with reimbursement frameworks are the challenges of prior authorization, which clinicians report are more cumbersome than ever. Balasky said his practice just hired a staff member to work solely on payment for genetic testing, because so many patients have been billed for this despite the growing role of precision medicine in cancer care. Vacirca said he’s interested in how Texas’ new “gold carding” law could set a standard that eliminates prior authorization for practices that can show that more than 90% of their requests are approved.
Unfortunately, Balasky said, too many payers have created incentives with brokers to build in utilization review and other steps that prevent quick payment for services. “The challenge I see, from my conversations with the insurance industry, [is that] they have built a piece that they can’t untangle,” he said.
Russo recalled a conversation with Vacirca on how this system forces practices to add staff and systems to keep payments flowing despite the barriers. “Revenue cycle management is the lifeblood of our practice,” Russo said.
Site of service. Russo shifted the discussion to a trend that took hold during the pandemic, in which practices are pressed to offer infusion in patients’ homes. The panelists agreed that this creates safety risks if physicians see patients less frequently, and that it’s an inefficient use of nurses’ time.
“It’s not really clear that there are actually cost savings, to the system or to the patient,” Touloukian said. When a patient is in the clinic, they are evaluated for iron levels and clinicians gain more insight into adverse events, which help prevent hospitalization.
“Something that community oncologists really excel at is bringing that sort of home experience into the clinic,” Touloukian said. “It’s one of our strengths.”
Both Balasky and Vacirca said the trend is rooted in a lack of attention to total cost of care and battles over which parts of cancer care are charged to a patient’s medical plan vs a prescription plan.
“In vertically integrated systems, it’s another way for the pharmacy benefits managers [PBMs] to bring in infusions onto themselves, to charge them back to the employers for huge amounts of money and then not be transparent about any of it,” Vacirca said.
Russo then asked about the future of telemedicine, and Touloukian said it will remain part of the landscape but perhaps be used differently than it was during the pandemic. For example, the ability to consult multiple family members on a telemedicine call to discuss a cancer patient’s treatment plan can be beneficial—Touloukian has helped members of her own family this way.
Remote monitoring will also evolve, as some patients appreciate extra contact while others don’t want to be bothered. The value of such contacts must be made clear in advance, Balasky said. Vacirca pointed out that remote monitoring is a more modern term for all the times physicians have been interrupted with questions and issues that come up between visits.
For years, doctors called patients after 5 pm to go over test results. “You’re missing your kids’ ball games, missing [your kids’] ballet [classes], and getting home at 8 o’clock,” Vacirca said. “We’ve done this our whole careers. Finally, there’s an opportunity for us to actually continue what we’re doing, to have that patient connection, to see the patient at the same time and get paid something for the work we do.”
Marketing community oncology. As consolidation and vertical integration drive up costs elsewhere, community oncology needs to find new ways to highlight its value.
“One of the things we learned through the pandemic was that we needed a better way to communicate with patients,” Russo said. Digital solutions to telling the story are necessary, as new competitors such as CVS Health and Optum enter the market. Vacirca said other community practices are being seen as collaborators and perhaps future partners, given the headwinds. “How do we grow and become more successful together?” he asked.
Balasky sees the major academic centers as offering complexity at a time when consumers want more simplicity. But community oncology needs to do more to communicate its value within local markets, and Russo agreed that more must be done with tools such as search engine optimization and social media to make sure practices get noticed.
There’s a good story to tell, Vacirca said, but until now, lack of transparency has made this difficult. “We just got transparency on premiums,” he said. “There’s no transparency on payers. The employers are waking up and realizing this.” Even his own practice is learning its lesson. For years the group had coverage through UnitedHealthcare; this year, after a switch to self-insurance, “the first thing we did was take the PBM out of the equation” and begin to manage drugs directly. “As an employer, it took 20% to 30% off the top.”
Personnel and burnout. Russo said the pandemic has offered new lessons to oncology practices, including the value of well-being. He spent the final minutes of the session on mental health among clinicians and the difficulty practices have finding staff. The generation of physicians trained in “work, work, work until you drop dead” is giving way to a new one that demands more attention to family and life priorities.
Mental health is “incredibly important” in community oncology, Touloukian said. “It’s going to look different for everybody,” she said, “not just from practice to practice but for each individual.”
Practices cannot passively wait to hear from staff members about scheduling problems or the need to work from home—they must go out and actively engage with the staff, Touloukian said. Russo said his own view on the subject has shifted: “We do have to figure out going forward, how do we manage that work-life balance, and what we do to assist them?”
Vacirca said changing culture includes empowering staff to communicate about the need for change. It can be as a simple as picking a different staff member each day to engage in a discussion about how they are doing.
“You’ll get to know every single person there. That’s how you change culture,” Vacirca emphasized. “And that’s how you create connections.”
Pilot Projects to Reduce Cancer Care Disparities Deserve Support, Speakers Say
Practice-level efforts to reduce cancer care disparities should be funded, because they offer “the only path forward” in achieving health equity, according to the head of a nonprofit that offers support services and financial assistance to patients.
Patricia J. Goldsmith, CEO of CancerCare, said a pilot project by Carolina Blood and Cancer Care Associates (CBCCA), centered in Rock Hill, South Carolina, should be replicated to reduce the number of cancer deaths that can be tied to patients’ income, housing situation, ethnic background, or other factors known as social determinants of health (SDOH).
Goldsmith appeared at a panel discussion on reducing disparities in care at the 2022 Community Oncology Conference, presented by the Community Oncology Alliance (COA). COA president Kashyap Patel, MD, discussed the initiative at CBCCA, where he serves as CEO. Early results from the project, called No One Left Alone (NOLA), appeared recently in Evidence-Based Oncology™, a publication of The American Journal of Managed Care®.1
In a yearlong pilot, CBCCA dedicated 2.5 full-time equivalent staff to helping patients with cancer secure free drugs or financial assistance for out-of-pocket costs, if they met income requirements. The initiative raised $1.7 million in various forms of financial assistance, helping nearly half the patients treated at CBCCA. The 154 patients who received help had a median household income of $38,766, well below the US and South Carolina median levels.1
Patel said NOLA has already moved into stages of the project that will help patients gain access to next-generation sequencing (NGS). Several speakers at COA said NGS presents unique reimbursement challenges, despite the mounting evidence in support of precision medicine. In the long term, Patel said, CBCCA will work to improve diversity in clinical trials; he said smaller practices like his are often excluded from participation, despite their ability to reach underrepresented populations.
“This is exactly what we need,” Goldsmith said. No single initiative will address all SDOH issues in cancer, so “we’re going to have to demonstrate results in small but very impactful ways.”
Nicolas Ferreyros, who serves as COA’s managing director for policy, advocacy and communications, moderated the panel and highlighted a study that COA undertook with Avalere Health; results were published ahead of the conference (see Cover). That study, which followed earlier work that documented the drop-off in cancer screenings during the early months of the COVID-19 pandemic, showed that screening rates did not recover evenly, and some minority groups still have lower screening rates than they did before the pandemic.
Ferreyros guided Patel through a discussion of how the quest to address disparities became a central focus for COA during Patel’s tenure as president. Patel said that the death of his father in 2019, combined with turning 60 years old, caused him to think more deeply about serving those with the greatest need. “In the last quarter of my life,” Patel said, “I decided to tackle disparities….This was almost like a higher calling.”
Ferreyros also highlighted data in a 2020 report from the American Association of Cancer Research that found that 34% of all cancer deaths are due to disparities.2
“Now, 34% does not sound like a huge number,” Patel said. But in absolute numbers, it translates to nearly 225,000 Americans each year. Those statistics should shock most people, but they don’t get enough attention, he said.3
One piece of COA’s effort to reduce disparities focuses on cancer screening. COA has collaborated with CancerCare and other partners on “Time to Screen,” which puts a focus on underserved groups. Susan Sabo-Wagner, RN, BSN, OCN, clinical director of Oncology Consultants in Houston, Texas, shared how materials were translated into Spanish, Vietnamese, Chinese, and Haitian-Creole.
Sabo-Wagner’s practice is using artificial intelligence (AI) to go a step beyond waiting for patients to miss an appointment or a treatment to learn that there’s a social or financial barrier to care. Building predictive models will identify which patients are likely to have problems with treatment adherence, she said.
“We have our advocates reaching out to patients with the resources,” said Sabo-Wagner, and then she organizes the follow-up to ensure that patients connect with available help. Using AI, demographic data, and a survey tool allows the practice to “pinpoint what we should be doing for patients, ahead of what we need to do.”
Patel agreed that cancer clinics often have no idea how SDOH affect patients unless they ask. He shared the story of one patient who had been living out of his car, but until the staff asked about his housing status, they were unaware of this fact.
Patel challenged the pharmaceutical industry to move beyond “the ivory tower” and ensure that community oncology practices have more research opportunities. Only then will the population in clinical trials start to represent the country’s diverse population, he said.
“The current model has failed,” Patel said. For instance, nearly a third of Americans have diabetes, he said, and these are the patients who show up at his clinic with cancer. Yet too few patients with comorbidities are permitted to take part in studies.
Goldsmith, who worked in academia before leading CancerCare, said she found it eye-opening to learn how big a difference small grants and support services can make to a patient with limited means. She commended Patel for creating NOLA without outside funding, forging ahead “because of your passion.”
1. Patel K, Mukhi H, Patel A, et al. Addressing cancer health disparities in a multilateral collaboration in an independent community cancer clinic: translating words into action. Am J Manag Care. 2022;28(SP6). Forthcoming. Published online March 15, 2022.
2. Sengupta R, Honey K. AACR Cancer Disparities Progress Report 2020: achieving the bold vision of health equity for racial and ethnic minorities and other underserved populations. Cancer Epidemiol Biomarkers Prev. 2020;29(10):1843. doi:10.1158/1055-9965.EPI-20-0269
3. Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2022. CA Cancer J Clin. 2022;72(1):7-33. doi:10.3322/caac.2170
Why Measures Matter—and How to Inspire Cancer Practices to Use Them
Quality measures are the lifeblood of practice transformation, but learning which ones make a difference—and how to use them to drive change—is as much an art as a science, according to 3 oncology care leaders who discussed the topic on March 18 at the 2022 Community Oncology Conference, presented by the Community Oncology Alliance.
Panelists Stephen Schleicher, MD, MBA, chief medical officer at Tennessee Oncology and medical director for value-based care for OneOncology, and Lalan Wilfong, MD, vice president for payer relations and practice transformation at The US Oncology Network and a longtime medical oncologist at Texas Oncology, joined moderator Alti Rahman, MBA, MHA, practice administrator for Oncology Consultants in Houston, Texas, for a session that covered gathering data and deploying it within a practice.
As Rahman explained, numbers on a dashboard don’t drive change all by themselves. He described a “transitional phase,” which is as much about conversations as the data. Physicians, nurses, and other staff must be educated on why data collection matters and how it can drive better patient care and improve the bottom line. It’s not a process that happens overnight, the panelists said.
As Schleicher put it, getting data into a dashboard is the easy part, but “the hard part is to get people to do something different.”
The panelists agreed that starting out slowly, with a focus on a few key measures that can identify “outliers,” is a good way to get buy-in without overwhelming care teams.
Schleicher and Wilfong stressed the importance of involving diverse stakeholders from across a practice. Wilfong said deciding who needs to be involved is important, and so is strong leadership. “At times, leadership has to say, ‘I know this isn’t pleasant, but we have to do it,’” he elaborated.
What happens, Rahman asked, when there is disagreement?
Schleicher advised that those who will be affected by a quality measure should have opportunities to weigh in on how it will be used. A given metric may be very important to some staff members and less important to others.
Wilfong said some metrics—such as how long it takes to schedule patients for appointments—must be monitored every day. But for other measures, including those that affect physicians, it may be better to measure less frequently, so that a single uncommon event such as a patient death doesn’t skew results. Schleicher said the question of how frequently to report metrics to fellow clinicians and the staff is one he’s still trying to answer.
“We’ve settled on quarterly for an extensive report,” Schleicher said.
Wilfong agreed: “Physicians don’t want stuff in front of them every single day.”
Rahman explored the merits of positive and negative reinforcement. Sending out emails that show physicians how they rank among their peers will often spark change among a group that is competitive by nature. But tying quality measures to compensation, such as a portion of the annual bonus, may be necessary.
Bonuses can be added dollars if quality measures improve, but they can also involve taking money if measures are poor. Wilfong said sometimes that’s what gets physicians to pay attention. In other words, he continued, “for some doctors, if you take $1 away, they completely freak out.”
Schleicher spoke at length of the care he takes in communicating subpar results. The process shouldn’t be about shaming people, but about having a conversation on why an individual physician is using a more expensive medication when a cheaper one will work. He said it’s important to realize that for many physicians, being compared with their peers is a relatively new concept.
“Before OneOncology had the tools to do this,” Schleicher explained, most clinicians had no idea how their resource utilization compared with that of others, and no clue “whether they were average or an outlier.”
Wilfong said US Oncology did an exercise that compared physician behavior in the context of a fee-for-service environment vs that of a risk-based model. Doctors went from thinking about an extra PET scan as something they could bill for to something that might cost them money. “As we take on more risk, the paradigm changes,” he said.
Schleicher emphasized the need to take things slowly, to balance driving change with ensuring that the data are accurate. For instance, if a physician is told he is an outlier in a metric and the data turn out to be wrong, trust is damaged. “Don’t send anything out if you’re not 100% confident,” he said. “If the quality is not there, it’s really hard to make up for it.”
Prior Authorization Woes Could Lead to Lawsuit, Former AMA President Says at COA
Prior authorization in cancer care has become so burdensome, costly, and harmful for patients that health plans and pharmacy benefit managers (PBMs) could face a lawsuit, the former president of the American Medical Association (AMA) said during a session on March 17 at the 2022 Community Oncology Conference, presented by the Community Oncology Alliance (COA).
Barbara McAneny, MD, CEO of the New Mexico Cancer Center, who served as AMA president in 2018, said the AMA has engaged a law firm to take on the issue of curtailing prior authorization. Oncologists say prior authorization abuses have increased with the rise of vertical integration among health plans and PBMs, causing treatment delays and overriding doctors’ attempts to use innovative therapies.
McAneny was a panelist in “Battle Royale: Payer Utilization Management vs Physician-Directed Medicine,” which was moderated by Debra Patt, MD, PhD, MBA, vice president of Texas Oncology, and also featured Leslie Busby, MD, chair of The US Oncology Network Pharmacy and Therapeutics Committee and an oncologist at Rocky Mountain Cancer Centers.
Although the oncologists said practices have had problems with prior authorization for years, McAneny noted that the situation has reached a crisis and is fueling clinician burnout. A recent demand that cancer patients be given an older, cheaper formulation of intravenous iron may be the example that propels litigation. For savings of $5 a unit, she said, patients have been forced to receive iron dextran (Infed), an iron replacement formulation known to cause more severe reactions than newer products.
The position of some payers, according to McAneny, is that “Infed is good enough—good luck with that iron reaction.” Although she and Patt agreed that going to court is never the first choice, sometimes it’s necessary. Finding the right plaintiff is the next step, McAneny said.
Both Patt and McAneny shared some alarming statistics on the burden that prior authorization creates for practices. Patt shared results of an AMA survey showing that 40% of physicians have staff who work exclusively on prior authorization, and that 93% of physicians report that patients have seen care delays. Patient harms are real, Patt said: “34% of physicians report that a prior authorization process has led to a serious adverse event [AE] for a patient in their care.”1
McAneny’s practice did a study that examined the time spent getting patients through the prior authorization process. The mean time spent waiting on hold for a single infusion approval was 18 minutes. “Now, keep in mind that we’re paying these people about $20 an hour. So that’s about $6 to sit on hold, which is really a good use of health care resources,” she said sarcastically.
Sometimes calls went quickly; in other cases, staff were on hold up to an hour. The mean number of days to get chemotherapy approved was 10.5 days. “That’s a lot of time for patients,” McAneny said.
Busby said he sees similar problems. In the past, delays in getting a new therapy approved were normal, but today, there are delays even for well-established regimens. The rise of “fail-first” policies—which require patients to take older, less effective treatments before trying new ones with demonstrated superiority—is harmful in cancer care, as evidence shows that using the best therapy first leads to the best outcomes.2 “That first treatment is very important,” Busby emphasized.
When a patient who takes an older chemotherapy starts vomiting, a cycle is established that can be very difficult to control. The fail-first approach is “penny wise and pound foolish,” Busby said. For practices that have value-based agreements in place that focus on total cost of care, he said, “1 hospitalization or 1 [emergency department] visit wipes out any savings.”
Patt, a breast cancer specialist, reported that payers sometimes treat all CDK4/6 inhibitors as if they are the same, even though their AE profiles may vary, especially for patients with underlying health issues. “Just because there are 3 doesn’t mean they are all equal,” she said.
Patt has seen cases in which a patient on a CDK4/6 inhibitor ends up taking the drug for 3 months, then must skip a month because of payer delays in renewing their prescription. It’s impossible to expect the drug to be as effective when this happens.
McAneny said a root of the problem is the lack of connection between health plan officials managing the medical side of costs vs those who are managing pharmacy benefits. The PBMs may be rewarded for “savings” because the costs of their decisions are borne elsewhere. “They don’t really bridge that gap very often,” she said.
Too often, health plans don’t understand the unique needs of cancer patients. Health plans try to tightly manage use of scans, McAneny said, because they worry about overuse in treatment for chronic back pain. But for a cancer patient, back pain can indicate that their disease has progressed, and scans must be timely.
Use of fail-first as a tool to enforce a restricted formulary is spreading, according to Busby. He said payers refer to barriers as “speed bumps,” because they know a certain number of physicians simply won’t push for a preferred treatment.
Even biosimilars are not exempt: Some PBMs demand that oncologists use a specific biosimilar even if the practice is using a different one for the same reference product. In these cases, patients receive appropriate treatment, but practices are “afraid that they won’t pay you for that treatment.”
What can be done? “There is a real role for advocacy,” Patt said. Reaching out to elected officials and lobbying partners is essential to heighten awareness, she stated.
Transparency will be essential to reform prior authorization, McAneny said, because it’s clear that rebates and financial incentives are driving mandates instead of what’s best for patients. Payers and PBMs should not be allowed to dictate care based on what’s “economically advantageous to the insurance company,” she said. Currently, she opined, “it’s all about the money.”
1. Physicians report prior authorization hurts workforce productivity. News release. American Medical Association; February 10, 2022. Accessed March 17, 2022. https://www.ama-assn.org/press-center/press-releases/physicians-report-prior-authorization-hurts-workforce-productivity
2. COA “fail-first” step therapy position statement. Community Oncology Alliance. September 19, 2019. Accessed March 20, 2022. https://communityoncology.org/position-statements/coa-fail-first-step-therapy-position-statement/
In Letter, COA Urges CMS to Do More to Rein in PBM Fees
The Community Oncology Alliance (COA) has urged CMS to take stronger action to regulate pharmacy benefit managers (PBMs), saying that without action, these entities will “abuse loopholes” despite the agency’s recent effort on “direct and indirect renumeration,” or DIR fees.
In a March 7 comment letter on CMS’ proposal to regulate PBM fees, COA leaders warned that without a stronger rule, the proposal’s positive effects could be erased. Specifically, COA recommends that all reimbursement provided to pharmacies should not be lower than the acquisition cost of the drugs dispensed.1
The issue, COA states, are DIR fees, a comparatively new type of revenue stream to PBMs imposed on independent and retail pharmacies, as well as pharmacies that are part of specialty cancer and urology practices. CMS has stated that the fees skyrocketed by 91,500% over the 10-year period ending in 2019.2 In statement released with the letter, COA said these fees are “unpredictable, nonnegotiable, and often ‘clawed back’ from pharmacy reimbursement months after prescriptions are dispensed.”1
COA asserts that DIR fees are tied to “irrelevant quality criteria” and cannot be contested. The effect on pharmacies and patients has been devastating, the group said. Because of claw back provisions, pharmacies have no idea what these fees will be, and the pharmacy could end up being paid less than a drug’s original cost.
“In some cases, pharmacies have been forced to close, most acutely jeopardizing patients in rural and underserved areas who are then forced to travel significant distances to get their medication,” COA states.
Kashyap Patel, MD, who is COA president and CEO of the Carolina Blood and Cancer Care Associates in Rock Hill, South Carolina, said patients ultimately pay the price because the fees drive up the cost of cancer treatment. “Ever since PBM behemoths have started to quietly take over the American health care system, cancer care has become more and more expensive, not less,” said Patel, who is also associate editor of Evidence-Based Oncology™.
COA’s 61-page letter raised concerns about multiple areas of the proposed rule; leaders urged CMS to exercise its authority to ensure that PBM amounts paid to pharmacies are “reasonable and relevant.”
At its annual meeting held March 16-18, COA leaders warned of the threat PBMs pose to in-house pharmacies at oncology practices. The ability to dispense drugs directly to patients is vital, the group states, because more and more oral drugs are being used in cancer care. This was especially true during the COVID-19 pandemic, when use of oral medications was preferred in some cases to prevent spread of infection.
1. Community oncologists urge CMS to take stronger action to curb pharmacy benefit manager fees. News release. Community Oncology Alliance. March 7, 2022. Accessed March 22, 2022. https://bit.ly/36ftOVL
2. Department of Health and Human Services. Justification of Estimates for Appropriations Committees, FY 2022. May 3, 2021. Accessed March 23, 2022. https://go.cms.gov/3Nf0dMD