The American Journal of Managed Care® sat down with Barbara McAneny, MD, president of the American Medical Association (AMA), to discuss how the AMA is working to "help create the healthcare system of the future."
These are changing times in oncology care. Breakthroughs in science have been tempered by the cost of treatments and CMS policy shifts over the past year, and leaders of major physician organizations were kept busy responding to various proposals to change Medicare reimbursement.1,2 Together with discussions about changing the way the government pays for prescription drugs3 and the possibility of a mandatory payment model in radiation oncology,4 the cancer care community is facing a time of unprecedented upheaval.
But oncologists have the right voice in the right place. In June, oncologist Barbara McAneny, MD, became the 173rd president of the American Medical Association (AMA),5 bringing her years of leadership in payment reform as the originator of the community oncology medical home (COME HOME) model6 to a broader advocacy role. Today, McAneny is taking on the AMA’s agenda of improving health outcomes, creating sustainable practice environments, advancing medical education, and attacking the opioid epidemic. Oncology, however, is never far from her mind, as it was in a recent interview with Surabhi Dangi-Garimella, PhD, associate editorial director for The American Journal of Managed Care®.
“We have a lot of work to do,” McAneny said. “There are a lot more changes to come, but I’m optimistic that the AMA is going to be able to help create the healthcare system of the future that is deserving of doctors’ work and patients’ respect, so that we don’t have the burnout issue and we can deliver better healthcare to patients at a lower cost.”
Developing Alternative Payment Models
McAneny discussed the need for CMS and other payers to build relationships with physicians, with a shared goal of delivering the best care to patients at the lowest possible cost. “We need to have that trusting partnership between the physicians and CMS and the other payers, instead of the adversarial relationship that it’s been in the past,” she said.
The movement away from fee-for-service reimbursement toward more alternative payment models (APMs) has created a process, through the Quality Payment Program, to develop more APMs. Not every model will look alike. “What works for inflammatory bowel disease may not be the same model that works for diabetes or cancer or heart disease,” McAneny said. “So, we need to have as many smart people as possible across the country thinking about this and coming up with models that CMS can test to be able to change this payment structure.”
CMS wants accountability, she said. “Patients are going broke out there. And we have to help them with that, as well.”
Care Coordination and the OCM
McAneny became known for her efforts as chief medical officer of New Mexico Oncology Hematology Consultants, where she developed the COME HOME model, which put a priority on improving outcomes and keeping patients out of the emergency department (ED) with expanded care coordination and 24/7 practice access. COME HOME was funded by the Center for Medicare and Medicaid Innovation and was a forerunner to the Oncology Care Model (OCM).6 COME HOME saved an average of $2100 per cancer patient by reducing ED and hospital visits, and delivering antibiotics or fluids in the office.
Besides the savings, quality of life improved. “Patients do not want to spend their time in the hospital,” McAneny said.
She sees the fruits of those efforts playing out in practices today. “I think that care management is focusing now on the low-hanging fruit of keeping people out of the hospital and keeping people out of the emergency departments.”
“There will always be cancer patients in the hospital, we will never get to zero on that,” McAneny continued. “But, if we set up our practices so that we can manage a lot of the side effects of cancer and its treatment in the lower-cost physician office setting, we can save significant amount of money.”
Helping Community Practices Thrive
The challenge, however, is connecting improved care to the right rewards structure. Community oncology practices have said they are under pressure from a reimbursement structure that is forcing many practices to close or merge with hopsitals.7 McAneny said it is “crucial” to help community practices thrive.
“I highly value community oncology. I think it is the low-cost, high-quality alternative to hospital-based systems, because under the hospital outpatient prospective payment system, that automatically costs the system twice as much,” McAneny said. “We’re the most expensive healthcare system on the planet. We cannot afford to pay twice as much for the same service....In addition, 40% of Americans live in rural areas. There are not going to be large, integrated systems in rural areas.”
To do this, she said, “We have to have a system that does not penalize physicians for doing the right thing for the right patient. The OCM has a practice adjuster that tries to look for how efficient they were before and has an early adopter factor that they put in for people who are using the new biologic agents, which are much better than standard chemotherapy. [They are] much less toxic [and have] better outcomes, so ethically we absolutely have to use those drugs. But they are also very expensive.”
McAneny repeated complaints of other oncologists, that the adjustment mechanisms in OCM do not go far enough to compensate practices that are using the most innovative therapies, which are, by definition, the most expensive.8
“The first thing we have to do, if we’re going to preserve community oncology, is to reward physicians, not penalize them for doing the right thing for patients.”
Payers must also consider that community practices must hire nurses with the same training levels as those at hospitals, along with professionals in data analytics—a need that did not exist a decade ago. “I now need technical people who can keep the [electronic health record] running,” she said. “So, the expense of practices has gone up significantly, but the payment from Medicare has not....We are penalized for trying to adapt. If they want practices to evolve, from fee-for-service into some sort of alternative payment model, CMS and the payers have to recognize that that evolution takes resources. We really need a system that will allow physician practices to have that margin so that we can invest in the future.”
To adapt, physician-owned practices have joined forces to create a National Cancer Care Alliance that provides what McAneny calls “bandwith” for managing functions such as information technology, HIPAA security, scheduling efficiency, and maximizing the effectiveness of electronic health records.
“If we band together, then we can delegate thinking about one of those problems to one of the people in the practice and then share the outcomes. So, that will really help us. And I think that’s going to be a good model for the future.”
Pathways to Success
CMS recently announced it sought to speed up the timetable for getting accountable care organizations (ACOs) to take on downside risk, through a revamped program called Pathways for Success.9 McAneny said the AMA expressed concerns about such a rapid transition. For starters, the ACOs that have only taken on 1-sided risk were saving more money than those taking on 2-sided risk.
“Since the goal of the ACOs is to deliver better healthcare at a lower price, we think that switching from the group that’s more successful at that and forcing everyone into a model where it hasn’t performed as well may be problematic,” she said.
Another AMA concern is CMS’ rapid move to let Medicare Advantage plans move to step therapy, which McAneny called a “fail first” program. “People often change their Medicare Advantage plans every year or 2 or plans change what they put as first-line drugs depending on the economics of what they purchase it for. That is incredibly disruptive for patients.
“For [patients with cancer], if we have to have patients fail first on the old-fashioned, less-expensive chemotherapy before they can get to the stuff that’s going to make a difference in their life, we’re going to do damage to people.”
The Trump administration has said it seeks to reduce paperwork and administrative burdens, which the AMA applauds, McAneny said. “But if now I have to go through this process, every time I treat a patient on a Medicare Advantage plan, to plead with them to let me give the patient the drugs that I think are better, they have just increased my documentation and physician burnout risk significantly.”
“We would like to be able to work with the administration to find better ways to save money. We absolutely agree that we need to save money in this system. We understand that physicians need to be held accountable for the quality of the care that we deliver,” she said. “We just think there are better ways to do it than the prior authorization process or the fail-first processes.”
Understanding Social Determinants of Health
Most people do not realize that the most important factor in determining a person’s health outcome is their ZIP code, McAneny said. It can determine whether the patient has a caregiver, whether the person can afford copays and deductibles—and yet these “social determinants of health” are not being measured.
“One of the things that the AMA is taking on, which I think is incredibly important, is how do we measure that? And how do we code for that in a respectful fashion, so that we can look at what that problem is?” she asked. “You can’t address a problem until you know how to define it and what the magnitude is.”
The AMA is working on a coding system, but it will take years. “We’re working to develop a coding system that will allow us to be able to stratify patients according to those risk factors, as well as what is your tumor type and are you also diabetic and all the other medical risk factors that are part of it. Because then we can truly judge whether or not a physician is doing the job we’re hoping they’re doing.
“You know, if they’re starting out with someone whose hemoglobin A1C is 14, and then get it down to 9, they’re doing a great job. But they would still be penalized under our current system.”REFERENCES