The Changing Landscape of Oncology

VBCC - June 2013, Volume 4, No 5 - AVBCC 2013 3rd Annual Conference
Caroline Helwick

Hollywood, FL—At the Third Annual Conference of the Association for Value-Based Cancer Care, 2 oncologists representing opposite corners of the oncology care landscape discussed the current trends in the delivery of patient care, and the challenges that are facing oncologists.

Robert W. Carlson, MD, the new Chief Executive Officer of the National Comprehensive Cancer Network (NCCN), called the new delivery
models and processes in oncology “the tip of the iceberg.”

“Oncology care is changing,” Dr Carlson said. The healthcare system has been struggling to institute Medicaid expansion, accountable care organizations (ACOs), medical homes, and bundled/episode-of-care payments, but things are about to get really interesting, he predicted.

“Health exchanges, or ‘marketplaces,’ will go live October 1. We are shifting the conversation, because in the next 8 months millions of individuals will be newly insured,” Dr Carlson noted.

He predicted that the private sector will drive the model “that ultimately works,” and the government will “hop in after the brain damage is suffered.”

How Will Health Exchanges Change the Picture?
Health exchanges (or marketplaces)must be established in each state by January 2014. Currently, there are 17 state-based (plus Washington, DC) exchanges, with 26 states defaulting to the federal exchange program, and 7 states planning for a partnership exchange.

“The exchanges are pretty much rolling along. A lot of rules are in place regarding central health benefits, which drugs are required to be provided, and network adequacy within the plans, with bronze, silver, platinum, and gold levels of risk. But one of the challenging issues,” Dr Carlson added, “will be explaining these to naïve insurance purchasers.”

From the community oncology practice perspective, Barbara L. McAneny, MD, Chief Executive Officer and Managing Partner of the New Mexico Cancer Center, Albuquerque, suggested that business will be brisk at first, because the newly insured are a population with “a pent-up demand”; however, “data show that after this point, things will stabilize.”

“A lot of these cancer patients have been receiving care but have not been able to select where they got that care,” Dr McAneny pointed out. “There is a big population who previously had to pick state-based institutions, and they can now shop with their feet and walk into my office to find the best value.”
Addressing how NCCN member institutions are dealing with the coming health exchanges, Dr Carlson noted that these cancer centers will have to adhere to the processes put in place within their own states, although this could get more complicated when organizations cross state lines.

“The Affordable Care Act has the risk of actually increasing, not decreasing, the variability of care in the United States,” Dr Carlson proposed.
Dr McAneny agreed, and noted that her practice has been approached by local payers “using this as a way to lock in market share by signing up physicians at low-cost Medicare levels.”

States that do not accept Medicaid expansion will have tremendous gaps in access to care, they both noted.

How Will Changes Be Communicated?
NCCN members are developing systems to handle the “huge bolus of patients arriving at their doors,” Dr Carlson said. One problem with communication could be access to patients. “Traditionally, the uninsured or marginally insured populations are difficult to get in contact with, and the typical systems we have as a society don’t work well with these groups.”

Dr McAneny said that, in her area, support services are embedded within the physician’s offices, and as such there is the opportunity for “teachable moments.”

“It will take a significant amount of patient education,” she said. “We are going to use our medical home project to work with federally qualified health services to manage patients.”

Accountable Care Organizations
Along with health exchanges, the oncology landscape should see the ramping up of cancer-specific ACOs, which have formed in many states. But there are no specialty ACOs within Medicare (which services 60% of the country’s patients with cancer), so this will be driven by the options offered within health exchanges, Dr Carlson pointed out.

He maintained that academic centers may be most suitable to the ACO model. “They are already organized in an ACO-like structure,” Dr Carlson pointed out, “but this is counterbalanced by challenges that are different from community practices.”

These challenges include the competing priorities of patient care, service, teaching, training, and research. “This fragments to some extent how each individual provider within these centers cares for patients,” and potentially compromises the continuum of care, Dr Carlson said. “At the end of the day, however, they will have to participate. The days of fee for service and buy and bill are almost over.”

By contrast, Dr McAneny has experience partnering with an ACO as a community oncology medical home (see article on the cover). She noted that the cost-savings with this model have already emerged.

Table
Table: Potential Cost-Savings from Medical Homes.
View larger version

Although the Centers for Medicare & Medicaid Services have attempted a variety of projects, she said, most have been based within large integrated health systems of hospitals and have not shown cost-savings—“until now, with the medical home projects” (Table).

Transformation Is Happening
With regard to payment and quality in oncology care, Dr Carlson said, “We are in a time of transition, and the timeline is short. Transformation is more likely than transition. We will see consolidation, because it’s hard for a single physician to impact quality. This means multiple physicians and multiple components in your office practice working in harmony.”

Dr Carlson predicted that bundled payments “are our future,” and considers this a positive change. “Bundled payments have the opportunity to realign the incentives for the patient, the provider, and the payer, but if, and only if, they are bundled with quality metrics to assure that the cost-savings are not achieved by sacrificing quality of care.”

Transformation in terms of drug pricing, however, is less predictable, he added. “It’s not going to be possible to have increased personalization of medicine at the expense of increased cost,” Dr Carlson commented, “so the big question is when and how the transformation in drug pricing will happen. The way we pay for drugs in oncology must change.”

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