The inaugural ASCO Oncology Practice Conference, held in Orlando, Florida, on March 2, brought together experts in the business of cancer care to discuss challenges faced by oncology practices. Leaders in the field covered a range of issues, especially those surrounding the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the advent of alternative payment models.
“This Meeting was created to try to meet the needs of oncology practices in maintaining and promoting quality cancer care while addressing the dynamic environment that we are challenged by every day, including regulatory, administrative, and legal matters,” said conference chair Robin Zon, MD, FACP, FASCO, of Michiana Hematology Oncology.
Dr. Zon called the meeting a “wonderful conference packed with great speakers” who had “passion and wisdom” for the topics covered by their talks.
MACRA Is Here
Philip J. Stella, MD, of St. Joseph Mercy Hospital, presented an overview of the final MACRA rule. He emphasized that now is the time for practices to implement the MACRA Quality Payment Program if they have not already. Practices participating in the Merit-based Incentive Payment System (MIPS) must record data on quality and other measures in 2017 and submit it by March 31, 2018. Their 2017 data submissions will result in positive or negative adjustments to their Medicare payments in 2019.
“You get a composite score,” Dr. Stella said. “Most of it this year, 60%, is based on quality.”
Other elements in the composite score for 2017 are Advancing Care Information (25%; formerly called Meaningful Use) and Improvement Activities (15%; a new category). In 2018, cost will be added as a fourth component of the MIPS composite score.
Each practice will be ranked against a National Median Composite Score.
“Practices below the median will get a penalty of 4%, and that money will be given to those above the composite score as an additional 4% bonus. This is a zero-sum game,” Dr. Stella said.
The inaugural ASCO Oncology Practice Conference brought together experts in the business of cancer care to discuss challenges faced by oncology practices.
A full explanation of MACRA implementation is beyond the scope of this article, but Dr. Stella urged practitioners to become familiar with ASCO’s Top Ten List for MACRA Readiness, available on asco.org, in order to ensure they do not incur penalties.
Seeking Useful Metrics
Brian Bourbeau, MBA, of Oncology Hematology Care, spoke about the need to identify useful quality measures for use with MIPS and other payers. He noted that currently, under the Physician Quality Reporting System, some practices are receiving penalties not because they perform poorly, “but because they struggle with reporting.”
Under MIPS, he said, a challenge for ASCO will be, “How do we set metrics that will support value-based care in oncology?” He said big data will play an important role in setting the direction.
The Bundle Jungle
The cost of cancer care is rising faster than the overall cost of health care, and cancer drugs are a big contributing factor, Blase N. Polite, MD, MPP, of the University of Chicago Medical Center, said. He spoke about the problems inherent in including drug costs in bundling of payments for cancer care.
Oncologists agree that drug cost inflation is not sustainable, but bundles are not the answer, Dr. Polite said. Practitioners have limited, if any, ability to control drug prices, and their ability to control utilization is overestimated.
“My utilization is based on who comes through my door,” he said.
The bottom line, Dr. Polite said, is that “oncologists should not be penalized for giving the right drug to the right patient at the right time. Any payment model that violates that—and I would argue that drug bundles violate that—should be excluded.”
Emerging Delivery Model
Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, president of the Levine Cancer Institute of Carolinas HealthCare System, said that hybrid academic-community cancer centers are emerging as a way to get new and effective treatments into the hands of community oncologists. These multisite centers, created by fusing teams of academic clinicians with practice oncologists, are “trying to overcome the tyranny of distance and save patients who are unwell from having to travel long distances,” he said.
Before the establishment of the Levine Cancer Institute, in 2011, many patients with cancer in the Carolinas had poor access to first-class care and research, particularly if they were in geographically remote areas, and the quality of care they received varied among providers. The hybrid academic-community cancer center system now includes 40 hospitals and 2,000 physicians, and it accounts for 12 million patient encounters each year. Oncologists and hospital presidents within the Carolinas HealthCare System participated in discussions to build a mechanism that suited their needs.
Dr. Raghavan said the benefits of the System, in addition to less travel and inconvenience for patients, include local access to sophisticated treatments, survivorship programs and support, genetic counseling via telemedicine, distributed access to cancer trials, care and access for uninsured or poorly insured patients, and fiscal advantages for members through shared purchasing and contracting.
Compensation and Value-Based Care
Karen K. Fields, MD, of H. Lee Moffitt Cancer Center and Research Institute, said her Center’s Clinical Pathways Program was designed to encourage collaboration about best practices, to personalize cancer care by patient factors and evidence rather than physician preferences, and to understand practice patterns and costs to prepare for collaborative discussions with payers related to accountable care. The Moffitt Cancer Center established its Clinical Pathways Program in 2009, and now has 55 disease-focused pathways that are integrated with electronic health records and workflow.
Moffitt Medical Group, owned by Moffitt Cancer Center, is composed of these interdisciplinary disease-focused teams. It transitioned from a largely productivity-based and individual-based incentive plan to team-based incentives over the past 4 years. The incentive pool is derived from up to 10% of physician groups’ productivity and is linked to overall institutional success. Incentives are focused on behaviors that support accountability, Dr. Fields said.
“It is critical to ensure institutional readiness for new payment models, including analytics capabilities, administrative support, and operational efficiency,” she said.
ASCO Clinical Pathways
Dr. Zon outlined ASCO’s policy statement recommendations and its proposed criteria for designing high-quality cancer care pathways. In late 2016, ASCO released a set of 15 criteria intended to guide stakeholders in assessing the quality, utility, and integrity of clinical pathways in oncology. Prior to the introduction of these criteria, she said the lack of standards to define high-quality pathways led to variations among programs.
According to Dr. Zon, pathways may be the cornerstone of future reimbursement methodologies and quality-of-life efforts. Payers are incentivizing oncologists to use clinical pathways by offering increased reimbursement, care management fees, and shared savings, she said.
ASCO’s criteria for high-value pathways focus on development, implementation and use, and analytics. Development should be transparent, evidence-based, patient-focused, and clinically driven, and should promote participation in clinical trials, she said. Outcomes should be clear and achievable, with efficient processes for communication and adjudication.
Save the date for the 2018 ASCO Oncology Practice Conference, to be held September 27, 2018, in Phoenix. Visit opc.asco.org for updates.
–Kathy Holliman, ELS, and Tim Donald, ELS