Download ASCO Update - National Coalition for Cancer Survivorship

Cancer Care Delivery Reform
Richard L. Schilsky, MD
Chief 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.”
A Growing Chorus
“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.”
Lee N. Newcomer, MD, MHA
Senior 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
Stewardship of Limited Resources
Question these things before doing them:
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.
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?
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
Chemotherapy Management Fee
• 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
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 timing