Panel weighs in on the changing face of oncology

Tomorrow’s oncologists are likely to be far busier, rely more heavily on information technology, and face greater scrutiny of the quality of their care than they do today, according to a panel convened at the conference. The panelists, who represented four leading US oncology professional associations, discussed the intense period of change the profession is going through, the driving forces behind that change, and what it all means for today’s oncologists.

The panelists identified uncertainty (specific and general), the changing healthcare environment, and an aging population as the specialty’s main challenges.

For Allen S. Lichter, MD, chief executive officer of the American Society of Clinical Oncology (ASCO) in Alexandria, Virginia, the uncertain future of single-specialty community-based practices topped his list of challenges. He expressed concern that current decisions about issues such as accountable care organizations and physician payment reform could stack the deck against such practices and drive physicians into multispecialty groups and hospital-based settings.

It’s important that the profession articulate the compelling reasons for preserving these practices, he said. “The argument for preservation will have to be a bit more substantial than ‘physicians have always practiced this way and enjoy practicing this way.’ It’s not that that’s not true, but it’s not compelling enough,” he said.

Matthew Farber, director of Provider Economics and Public Policy with the Association of Community Cancer Centers in Rockville, Maryland, cited the changing healthcare environment as another challenge. This includes not only how and where care is being given as a result of consolidation and cooperation of practices and hospitals, but the nature of that care—for example, with the trend away from infusional therapy and toward oral therapy. 

In addition, the old model (buy-and-bill, fee for service) is being replaced by pathways, benchmarks, bundling of care, and episodic care. “If you are not already experiencing them in your own practices, get ready,” Mr. Farber said. He encouraged oncologists to be preemptive in negotiating changes that protect their interests, to get involved, and to stay abreast of the changes. 

Another panelist, Matthew E. Brow, vice president of Corporate Communications, Government Relations & Public Policy with US Oncology in Washington, DC, believes an aging population and the entry of the Baby Boomers into Medicare will present a key hurdle for the specialty. Between now and 2020, the number of Medicare beneficiaries will increase by nearly 35%, and the impact of that increase will be “significant and far reaching.” Oncologists will be expected to see more patients, which will put intense pressure on the reimbursement rate, he noted. The combination of a larger Medicare patient population and declining reimbursement could make it increasingly difficult for practices to remain financially viable.

Ted A. Okon, MBA, executive director of the Washington, DC-based Community Oncology Alliance, sees overall uncertainty as a consuming challenge, whether it’s about near-term concerns, such as the sustainable growth rate (SGR), or longer-term concerns, such as whether or not there will be healthcare reform. “It’s very difficult because the economic laws still pertain,” he observed. “You have to operate a practice as a business, and it is next to impossible to do so in an uncertain environment.”

On the positive side, the Patient Protection and Affordable Care Act (PPACA) eliminates lifetime caps and copays on screening and preventive services and gradually will close the infamous doughnut hole, Dr. Lichter said. But its physician payment reform is worrisome. 

“I have not spoken to anyone in healthcare who has said that physician payment, basically a fee-for-service reimbursement, will persist untouched,” he said. “There will be new models of physician payment reform. We have to work on understanding them and making sure the changes work, and if they are not to our benefit, we must at least ensure we don’t go backwards.”

Mr. Brow added that another benefit of the PPACA for community oncology will be the creation of a large new population of individuals with private health insurance. Private payers “are almost certainly paying better than Medicare is paying today and will likely pay in 2014 and 2015.  This will help offset the impact on practice revenue of growth in the Medicare segment,” he said. The legislation will also substantially expand the Medicaid population, but since Medicaid patients make up only 3%–5% of community oncologists’ patients, and given the swelling Medicare ranks, it will not have much impact on these oncologists unless they see a largely pediatric population.

However, Mr. Okon cautioned that the PPACA “is actually pushing the private payers to move very rapidly, and we are seeing a lot of changes on the private payer side,” such as increasing patients’ share of costs.

Dr. Lichter encouraged oncologists to think of offering some form of robust quality performance measurement as a means of resolving the SGR impasse. They could show that they are practicing oncology medicine in a way that is cost-effective, that they are measuring their performance, and that they have the numbers to show it. For instance, early experience with the oncology medical home has proven that it is possible to document improved outcomes, such as fewer hospitalizations, he said.

“Unfortunately, we are still in a cycle of short-term fixes” for the SGR, Mr. Farber said. A long-term fix is unlikely in 2011, and physicians will probably have to wait until the end of the year to learn the details of the next patch. The problem is the cost, which now stands at $300 billion. “It is too expensive to fix and has become one giant accounting error at this point,” he said. “We can’t handle a 25%–30% reduction in our Medicare rates, and I don’t believe Congress would allow that to stay on the books. The big question is, what will they replace it with? A 0% update, a 1% update, or a negative 1% update?” 

At present, roughly 20 groups claim to be the arbiters of oncology quality measurement. All of the panelists agreed that physicians need to play an active role in devising and running a quality program. “We are all going to be measured, and the results of that measurement will be made public,” Dr. Lichter noted. “There is a compelling reason for us to unite behind a quality program in which we all participate and to make that the standard,” he asserted. “It should be physician run and physician directed. We are the only group that can truly judge physicians’ quality.”

He said that ASCO’s Quality Oncology Practice Initiative (QOPI), which allows oncologists to compare the quality of their care with that of their peers, is limited by its retrospective and labor-intensive nature. But with the conversion to electronic records, it could provide information in real time and even be used for decision support.

Mr. Farber agreed with Dr. Lichter, but added that “the hard part, especially in oncology, is to define quality and a valuable treatment. You might provide…the highest quality of care, yet the patient outcome might still be negative.”

Mr. Okon said although the community oncology model is efficient, “the onus is on us to prove it.” Here, the medical home model is getting attention, with its dual emphasis on quality and efficiency. It shows that there can be an increase in quality concurrent with an increase in efficiency and cost-effectiveness.”

There are no direct efforts under way to increase the oncology workforce, according to Dr. Lichter. “We’ve got to learn how to care for patients with the number of people we have,” he said. Physicians are not trained in process improvement and are hard-pressed to find time to analyze their workflow, but doing so will be critical, he commented. 

Mr. Brow predicted that “practices are going to have to see more patients per physician to stay in the same place,” given the growth in the Medicare population and the lack of corresponding growth in the oncology profession. To meet this objective, he endorsed the use of physician extenders, such as physician assistants and nurse practitioners, and a structured approach to improve the efficiency of the practice, such as working unconventional hours or doing workflow analyses and revamping staffing models. Applying Lean Six Sigma principles, which have been used to boost efficiency in other industries, could also go a long way in this regard, he added. 

But Mr. Okon contended that regardless of oncologists’ numbers and efficiency, patients’ access to cancer care might well boil down to the extent of their insurance coverage. He predicted that underinsurance would be an unintended consequence of the new healthcare reform. “It is going to be a crisis point in oncology, because…we are seeing the private payers already reacting to healthcare reform so that there is going to be more burden on the individual.” 

This shift in costs to patients is not a problem for most minor ailments, Mr. Okon said, but it is another matter entirely when it comes to cancer.

None of the panelists had any conflicts of interest to disclose.

Tomorrow’s oncologists are likely to be far busier, rely more heavily on information technology, and face greater scrutiny of the quality of their care than they do today, according to a panel convened at the conference. The panelists, who represented four leading US oncology professional associations, discussed the intense period of change the profession is going through, the driving forces behind that change, and what it all means for today’s oncologists.

The panelists identified uncertainty (specific and general), the changing healthcare environment, and an aging population as the specialty’s main challenges.

For Allen S. Lichter, MD, chief executive officer of the American Society of Clinical Oncology (ASCO) in Alexandria, Virginia, the uncertain future of single-specialty community-based practices topped his list of challenges. He expressed concern that current decisions about issues such as accountable care organizations and physician payment reform could stack the deck against such practices and drive physicians into multispecialty groups and hospital-based settings.

It’s important that the profession articulate the compelling reasons for preserving these practices, he said. “The argument for preservation will have to be a bit more substantial than ‘physicians have always practiced this way and enjoy practicing this way.’ It’s not that that’s not true, but it’s not compelling enough,” he said.

Matthew Farber, director of Provider Economics and Public Policy with the Association of Community Cancer Centers in Rockville, Maryland, cited the changing healthcare environment as another challenge. This includes not only how and where care is being given as a result of consolidation and cooperation of practices and hospitals, but the nature of that care—for example, with the trend away from infusional therapy and toward oral therapy. 

In addition, the old model (buy-and-bill, fee for service) is being replaced by pathways, benchmarks, bundling of care, and episodic care. “If you are not already experiencing them in your own practices, get ready,” Mr. Farber said. He encouraged oncologists to be preemptive in negotiating changes that protect their interests, to get involved, and to stay abreast of the changes. 

Another panelist, Matthew E. Brow, vice president of Corporate Communications, Government Relations & Public Policy with US Oncology in Washington, DC, believes an aging population and the entry of the Baby Boomers into Medicare will present a key hurdle for the specialty. Between now and 2020, the number of Medicare beneficiaries will increase by nearly 35%, and the impact of that increase will be “significant and far reaching.” Oncologists will be expected to see more patients, which will put intense pressure on the reimbursement rate, he noted. The combination of a larger Medicare patient population and declining reimbursement could make it increasingly difficult for practices to remain financially viable.

Ted A. Okon, MBA, executive director of the Washington, DC-based Community Oncology Alliance, sees overall uncertainty as a consuming challenge, whether it’s about near-term concerns, such as the sustainable growth rate (SGR), or longer-term concerns, such as whether or not there will be healthcare reform. “It’s very difficult because the economic laws still pertain,” he observed. “You have to operate a practice as a business, and it is next to impossible to do so in an uncertain environment.”

On the positive side, the Patient Protection and Affordable Care Act (PPACA) eliminates lifetime caps and copays on screening and preventive services and gradually will close the infamous doughnut hole, Dr. Lichter said. But its physician payment reform is worrisome. 

“I have not spoken to anyone in healthcare who has said that physician payment, basically a fee-for-service reimbursement, will persist untouched,” he said. “There will be new models of physician payment reform. We have to work on understanding them and making sure the changes work, and if they are not to our benefit, we must at least ensure we don’t go backwards.”

Mr. Brow added that another benefit of the PPACA for community oncology will be the creation of a large new population of individuals with private health insurance. Private payers “are almost certainly paying better than Medicare is paying today and will likely pay in 2014 and 2015.  This will help offset the impact on practice revenue of growth in the Medicare segment,” he said. The legislation will also substantially expand the Medicaid population, but since Medicaid patients make up only 3%–5% of community oncologists’ patients, and given the swelling Medicare ranks, it will not have much impact on these oncologists unless they see a largely pediatric population.

However, Mr. Okon cautioned that the PPACA “is actually pushing the private payers to move very rapidly, and we are seeing a lot of changes on the private payer side,” such as increasing patients’ share of costs.

Dr. Lichter encouraged oncologists to think of offering some form of robust quality performance measurement as a means of resolving the SGR impasse. They could show that they are practicing oncology medicine in a way that is cost-effective, that they are measuring their performance, and that they have the numbers to show it. For instance, early experience with the oncology medical home has proven that it is possible to document improved outcomes, such as fewer hospitalizations, he said.

“Unfortunately, we are still in a cycle of short-term fixes” for the SGR, Mr. Farber said. A long-term fix is unlikely in 2011, and physicians will probably have to wait until the end of the year to learn the details of the next patch. The problem is the cost, which now stands at $300 billion. “It is too expensive to fix and has become one giant accounting error at this point,” he said. “We can’t handle a 25%–30% reduction in our Medicare rates, and I don’t believe Congress would allow that to stay on the books. The big question is, what will they replace it with? A 0% update, a 1% update, or a negative 1% update?” 

At present, roughly 20 groups claim to be the arbiters of oncology quality measurement. All of the panelists agreed that physicians need to play an active role in devising and running a quality program. “We are all going to be measured, and the results of that measurement will be made public,” Dr. Lichter noted. “There is a compelling reason for us to unite behind a quality program in which we all participate and to make that the standard,” he asserted. “It should be physician run and physician directed. We are the only group that can truly judge physicians’ quality.”

He said that ASCO’s Quality Oncology Practice Initiative (QOPI), which allows oncologists to compare the quality of their care with that of their peers, is limited by its retrospective and labor-intensive nature. But with the conversion to electronic records, it could provide information in real time and even be used for decision support.

Mr. Farber agreed with Dr. Lichter, but added that “the hard part, especially in oncology, is to define quality and a valuable treatment. You might provide…the highest quality of care, yet the patient outcome might still be negative.”

Mr. Okon said although the community oncology model is efficient, “the onus is on us to prove it.” Here, the medical home model is getting attention, with its dual emphasis on quality and efficiency. It shows that there can be an increase in quality concurrent with an increase in efficiency and cost-effectiveness.”

There are no direct efforts under way to increase the oncology workforce, according to Dr. Lichter. “We’ve got to learn how to care for patients with the number of people we have,” he said. Physicians are not trained in process improvement and are hard-pressed to find time to analyze their workflow, but doing so will be critical, he commented. 

Mr. Brow predicted that “practices are going to have to see more patients per physician to stay in the same place,” given the growth in the Medicare population and the lack of corresponding growth in the oncology profession. To meet this objective, he endorsed the use of physician extenders, such as physician assistants and nurse practitioners, and a structured approach to improve the efficiency of the practice, such as working unconventional hours or doing workflow analyses and revamping staffing models. Applying Lean Six Sigma principles, which have been used to boost efficiency in other industries, could also go a long way in this regard, he added. 

But Mr. Okon contended that regardless of oncologists’ numbers and efficiency, patients’ access to cancer care might well boil down to the extent of their insurance coverage. He predicted that underinsurance would be an unintended consequence of the new healthcare reform. “It is going to be a crisis point in oncology, because…we are seeing the private payers already reacting to healthcare reform so that there is going to be more burden on the individual.” 

This shift in costs to patients is not a problem for most minor ailments, Mr. Okon said, but it is another matter entirely when it comes to cancer.

None of the panelists had any conflicts of interest to disclose.

Tomorrow’s oncologists are likely to be far busier, rely more heavily on information technology, and face greater scrutiny of the quality of their care than they do today, according to a panel convened at the conference. The panelists, who represented four leading US oncology professional associations, discussed the intense period of change the profession is going through, the driving forces behind that change, and what it all means for today’s oncologists.

The panelists identified uncertainty (specific and general), the changing healthcare environment, and an aging population as the specialty’s main challenges.

For Allen S. Lichter, MD, chief executive officer of the American Society of Clinical Oncology (ASCO) in Alexandria, Virginia, the uncertain future of single-specialty community-based practices topped his list of challenges. He expressed concern that current decisions about issues such as accountable care organizations and physician payment reform could stack the deck against such practices and drive physicians into multispecialty groups and hospital-based settings.

It’s important that the profession articulate the compelling reasons for preserving these practices, he said. “The argument for preservation will have to be a bit more substantial than ‘physicians have always practiced this way and enjoy practicing this way.’ It’s not that that’s not true, but it’s not compelling enough,” he said.

Matthew Farber, director of Provider Economics and Public Policy with the Association of Community Cancer Centers in Rockville, Maryland, cited the changing healthcare environment as another challenge. This includes not only how and where care is being given as a result of consolidation and cooperation of practices and hospitals, but the nature of that care—for example, with the trend away from infusional therapy and toward oral therapy. 

In addition, the old model (buy-and-bill, fee for service) is being replaced by pathways, benchmarks, bundling of care, and episodic care. “If you are not already experiencing them in your own practices, get ready,” Mr. Farber said. He encouraged oncologists to be preemptive in negotiating changes that protect their interests, to get involved, and to stay abreast of the changes. 

Another panelist, Matthew E. Brow, vice president of Corporate Communications, Government Relations & Public Policy with US Oncology in Washington, DC, believes an aging population and the entry of the Baby Boomers into Medicare will present a key hurdle for the specialty. Between now and 2020, the number of Medicare beneficiaries will increase by nearly 35%, and the impact of that increase will be “significant and far reaching.” Oncologists will be expected to see more patients, which will put intense pressure on the reimbursement rate, he noted. The combination of a larger Medicare patient population and declining reimbursement could make it increasingly difficult for practices to remain financially viable.

Ted A. Okon, MBA, executive director of the Washington, DC-based Community Oncology Alliance, sees overall uncertainty as a consuming challenge, whether it’s about near-term concerns, such as the sustainable growth rate (SGR), or longer-term concerns, such as whether or not there will be healthcare reform. “It’s very difficult because the economic laws still pertain,” he observed. “You have to operate a practice as a business, and it is next to impossible to do so in an uncertain environment.”

On the positive side, the Patient Protection and Affordable Care Act (PPACA) eliminates lifetime caps and copays on screening and preventive services and gradually will close the infamous doughnut hole, Dr. Lichter said. But its physician payment reform is worrisome. 

“I have not spoken to anyone in healthcare who has said that physician payment, basically a fee-for-service reimbursement, will persist untouched,” he said. “There will be new models of physician payment reform. We have to work on understanding them and making sure the changes work, and if they are not to our benefit, we must at least ensure we don’t go backwards.”

Mr. Brow added that another benefit of the PPACA for community oncology will be the creation of a large new population of individuals with private health insurance. Private payers “are almost certainly paying better than Medicare is paying today and will likely pay in 2014 and 2015.  This will help offset the impact on practice revenue of growth in the Medicare segment,” he said. The legislation will also substantially expand the Medicaid population, but since Medicaid patients make up only 3%–5% of community oncologists’ patients, and given the swelling Medicare ranks, it will not have much impact on these oncologists unless they see a largely pediatric population.

However, Mr. Okon cautioned that the PPACA “is actually pushing the private payers to move very rapidly, and we are seeing a lot of changes on the private payer side,” such as increasing patients’ share of costs.

Dr. Lichter encouraged oncologists to think of offering some form of robust quality performance measurement as a means of resolving the SGR impasse. They could show that they are practicing oncology medicine in a way that is cost-effective, that they are measuring their performance, and that they have the numbers to show it. For instance, early experience with the oncology medical home has proven that it is possible to document improved outcomes, such as fewer hospitalizations, he said.

“Unfortunately, we are still in a cycle of short-term fixes” for the SGR, Mr. Farber said. A long-term fix is unlikely in 2011, and physicians will probably have to wait until the end of the year to learn the details of the next patch. The problem is the cost, which now stands at $300 billion. “It is too expensive to fix and has become one giant accounting error at this point,” he said. “We can’t handle a 25%–30% reduction in our Medicare rates, and I don’t believe Congress would allow that to stay on the books. The big question is, what will they replace it with? A 0% update, a 1% update, or a negative 1% update?” 

At present, roughly 20 groups claim to be the arbiters of oncology quality measurement. All of the panelists agreed that physicians need to play an active role in devising and running a quality program. “We are all going to be measured, and the results of that measurement will be made public,” Dr. Lichter noted. “There is a compelling reason for us to unite behind a quality program in which we all participate and to make that the standard,” he asserted. “It should be physician run and physician directed. We are the only group that can truly judge physicians’ quality.”

He said that ASCO’s Quality Oncology Practice Initiative (QOPI), which allows oncologists to compare the quality of their care with that of their peers, is limited by its retrospective and labor-intensive nature. But with the conversion to electronic records, it could provide information in real time and even be used for decision support.

Mr. Farber agreed with Dr. Lichter, but added that “the hard part, especially in oncology, is to define quality and a valuable treatment. You might provide…the highest quality of care, yet the patient outcome might still be negative.”

Mr. Okon said although the community oncology model is efficient, “the onus is on us to prove it.” Here, the medical home model is getting attention, with its dual emphasis on quality and efficiency. It shows that there can be an increase in quality concurrent with an increase in efficiency and cost-effectiveness.”

There are no direct efforts under way to increase the oncology workforce, according to Dr. Lichter. “We’ve got to learn how to care for patients with the number of people we have,” he said. Physicians are not trained in process improvement and are hard-pressed to find time to analyze their workflow, but doing so will be critical, he commented. 

Mr. Brow predicted that “practices are going to have to see more patients per physician to stay in the same place,” given the growth in the Medicare population and the lack of corresponding growth in the oncology profession. To meet this objective, he endorsed the use of physician extenders, such as physician assistants and nurse practitioners, and a structured approach to improve the efficiency of the practice, such as working unconventional hours or doing workflow analyses and revamping staffing models. Applying Lean Six Sigma principles, which have been used to boost efficiency in other industries, could also go a long way in this regard, he added. 

But Mr. Okon contended that regardless of oncologists’ numbers and efficiency, patients’ access to cancer care might well boil down to the extent of their insurance coverage. He predicted that underinsurance would be an unintended consequence of the new healthcare reform. “It is going to be a crisis point in oncology, because…we are seeing the private payers already reacting to healthcare reform so that there is going to be more burden on the individual.” 

This shift in costs to patients is not a problem for most minor ailments, Mr. Okon said, but it is another matter entirely when it comes to cancer.

None of the panelists had any conflicts of interest to disclose.