Cancer Care Delivery Reform

Richard L. Schilsky, MDChief Medical Officer

ASCO

What’s The Goal?

• Provide each patient the opportunity to obtain the best possible outcome of their cancer care

• Deliver high quality, efficient, evidence based care

• Provide value in cancer care for both patients and the healthcare system

Motivating Factors

• Legislation• Regulation• Reimbursement• Certification• Litigation

Why We Need Payment Reform

• Fee for service medicine incentivizes quantity, not quality

• That has led to runaway cost

• Medicare has attempted various controls. Examples:– Setting fees– A fixed pie – Annual spending limits– Administrative controls (e.g., preauthorization, audits, etc.)

This is a failed model. There has to be a better way.

Whether We Like it or Not…

“Medicare emerging as prime target in U.S. "fiscal cliff" talks” Reuters, Dec 5

“…means-testing, or more expensive premiums for wealthy retirees, raising the eligibility age from 65 to 67, lowering provider reimbursements, and changing drug benefits. Democrats and Republicans are hoping to find between $400 billion and $600 billion of healthcare savings over the next decade, most of which will come from Medicare.”

“The current system of oncology drug revenue dependence was created 40 years ago. No one thought it would be a problem, but it is, and it’s vital that we address ways to fix it.”

A Growing Chorus

Lee N. Newcomer, MD, MHASenior Vice President, Oncology

UnitedHealthcare

Reforms Beginning…More to Come• Most people agree that fee for service is

fading away in favor of prospective payment models– ACOs– Episode or bundled payments– PCMH

• These models shift risk from payers to providers– Oncologists already absorbing millions in risk with

drugs– Smaller practices straining or buckling– May be the last straw for community practices

Surviving in a World of Bundled Payments

Given the pace of price increases for chemotherapy drugs, it will be nearly impossible to set bundled payments—or to live within a capitated environment that includes drug costs

– Physicians will be forced to use lowest cost—not necessarily most appropriate—treatment to stay within budget

– If bundles grow at the rate of medical inflation—and drug prices grow at the current rate—it will be a race to the bottom

What’s the Answer?

• Physician leadership in proposing solutions

• Test multiple models to see what is feasible and conducive to a healthy cancer care delivery system

• Place risk on things oncologists can control (services)—not on things they can’t control (price of drugs)

Why Acting Now May be Prudent

• ASP+6 has been on every deficit reduction list and will continue to rise higher on an increasingly short list. Reductions to 2% have been suggested.

• Waiting might mean lower ASP, weaker negotiating position, fewer resources retained in the system

• Offering alternatives now may be a chance to transform 6% into a “management fee”—can still show savings

• Every 1% reduction = ~$155 million/year

Why Some Think No Action Is Needed• This is a game of “chicken” and we are blinking

• Some practices healthy under ASP; some can survive even if the percent is lowered

• Some physicians near retirement want to ride this out

• Belief that ASP is a “hot potato”—Congress won’t see enough savings to endure fallout

• Depending on the consultant, different opinions about likely scenario

However, even if Congress doesn’t touch ASP, the system is on its way to one in which fee for service is disappearing. A cohesive plan is critical.

ASCO’s Strategy

• Develop alternative payment models so they are ready regardless of timing– Timing uncertain, but Congressional staff pressing

for proposals now• Protect current resources until we test new

models– Oppose cuts to ASP for now

• Advance unified oncology quality reporting – Proliferation of quality programs becoming

harmful– Reporting burden escalating; often not meaningful– Quality measurement critical in prospective

payment

What is ASCO Doing?

• Engaging with members of Congress

• Exploring payment reform alternatives to avert SGR cuts for oncology

• Participating in AMA and other specialty society advocacy efforts

…and working on things we can do

now…

Stewardship of Limited Resources

1. Use of chemotherapy for patients with advanced cancers who are unlikely to benefit, and who would gain more from a focus on palliative care and symptom management.

2. For early breast cancer, use of advanced imaging technologies (i.e., CT, PET and radionuclide bone scans) in cancer staging.

3. For early prostate cancer, use of advanced imaging technologies (i.e., CT, PET and radionuclide bone scans) in cancer staging.

4. Routine use of advanced imaging and blood biomarker tests for women treated with curative therapy for breast cancer and who have no symptoms of recurrence.

5. Use of white cell stimulating factors for patients who are at low risk for febrile neutropenia.

Question these things before doing them:

How Were These Chosen?

• Led by ASCO Cost of Cancer Care Task Force– Multidisciplinary group of oncologists

• Based on comprehensive review of published studies, guidelines from ASCO and other organizations

• Input from more than 200 oncologists– Practicing oncologists– State society leaders

– Patient advocates

What’s Next?

• ASCO University programs

• Education session at Annual Meeting

• JOP article in July

• Benchmarking practice and financial impact

• Comprehensive information on Cancer.Net

• Integrate with quality improvement programs

• Developing items 6 through 10

Support Clinical Decision Making: Regimen Advisor Tool

• Allows assessment of benefit, toxicity and cost across regimens

• Supports patient-physician communication, decision-making

• Pilot nearing completion

Anticipate Trends to Support Practice

How many medical oncologists are there?

How many practices? How many sites?

What are the access issues?

How many solo practitioners are there?

What percentage of practices are hospital based?

Referral patterns?Study results in Jan 2013 JOP

Demonstrating Value

• Implementation of QOPI as a national platform – Current focus is on federal requirements and regulation– Long term goal is to have QOPI deemed for all payers– Avoid creation of separate program for each payer

• Active dialogue with key Congressional committees

• Parallel outreach to senior leaders at CMS

• ASCO led development of multi-specialty consensus on criteria for deeming registries

– ACC, ASCO, AGA, and others support– Criteria used to draft legislative language– Language successfully included in fiscal cliff bill– Task is now implementing rules

Assessing Alternative Models

• Chemotherapy management fee

• Bundled payments

• PCMH

New Ideas

 

• Drugs paid for at cost (“pass through”)

• Replace ASP + 6 with “Chemotherapy Management Fee”

• Paid on a monthly basis

• Change is income neutral, further increases based on performance, quality improvement

• Fee adjusted upward each year based on performance and/or MEI or another index; these upward adjustments should be smaller than the rapid increase in the price of drugs

Chemotherapy Management Fee

What We’ve Done

• CPC workgroup is working on detailed concept draft

• Detailed specs shared with volunteer practices who have agreed to pilot/assess impact

• Next step will be member/community outreach to test concepts, get input

Bundling

• Time- and/or condition-defined • Flat fee, single payment

• May or may not include drugs

• Efficiencies developed at practice level

• Potential for choice of less expensive drugs

What We’ve Done

• Initial bundling proposal sent to Center for Medicare and Medicaid Innovation in 2009;– Colon cancer– No reaction from CMS

• Recent signal from CMS that views have changed on need for “immediate” wins and savings– Updated and resubmitted colon cancer demo– No reaction to date

Patient Centered Medical Home• Facilitates partnerships between individual

patients, personal physicians

• Care facilitated through registries, information technology, health information exchange and other means to assure care coordination and disease management

• Role of specialists evolving

What We’ve Done

• Working with NCQA and others in oncology community to define specialty specific standards

• Pilot planned for this year

Whatever the path…• Fee for service unlikely to remain dominant model

• Prospective payment models are the trend– Shifts reward from volume to efficiency– Risk will move from over- to under-utilization– Because of this, require strong quality measurement

programs

• Need a national program created by—and meaningful to—oncology professionals

• Any model must be tested for a reasonable amount of time (i.e., demonstrations, pilots, etc.) to determine impact

– 3-5 years

Challenges Ahead

• Getting the timing right: Need to share proposal before ASP gets cut.

• Clear understanding about impact/risk of new models across community/profession/industry—analysis takes time and money

• Role/impact of payment reform on 340b program

• Designing new drug acquisition process that meets the needs of all stakeholders

The Biggest Challenge of All: Community Consensus

• Diverse stakeholders

• Varying perspective, depending on practice

• Measuring impact

• Uncertain timingBut a divided community will

not produce a healthy outcome