2014 Forecast Series-ASCO Priorities and Objectives
With Allen S. Lichter, MD
Allen S. Lichter, MD, is the Chief Executive Officer of the American Society of Clinical Oncology (ASCO), which represents nearly 35,000 physicians and health professionals in oncology worldwide.
OBR: What are some of the major priorities and objectives that you see in 2014 and how do they contrast with 2013?
AL: A lot of the things we’re carrying into 2014 are long-term objectives. From a policy perspective, repealing the SGR is a critical task and it looks like it can actually happen. The legislation isn’t perfect, but the direction it’s going puts us in a far better place, certainly better than with this constant cut hanging over our heads, and periodic suspension of all payments, while we become a political football on the Congressional football field. We are anxious to see a resolution of this problem.
And then, that begins to lead into physician payment reform. We’ve been working with our colleagues at COA and US Oncology and others to formulate our best ideas of what to test. It’s our feeling and the feeling of our partners that we’d like to be one of the lead specialties in moving new ideas forward, rather than one of the trailing specialties, so we think 2014 will be a fairly important year around physician payment reform.
We’re also working with CMS about certifying our QOPI registry and satisfying all of the PQRS reporting requirements. The regulations that would allow such things to happen have been produced and we are now assessing how QOPI fits into this. I would say one of the biggest stumbling blocks is that QOPI, correctly, focuses on practice evaluation, not individual physician evaluation. That’s because you start to get into the law of small numbers when you start to get down to the care of individual physicians, especially in any community practice where each physician is in fact a generalist. The regulations say that if a quality registry is going to be deemed by CMS, it has to focus at the individual physician level – we understand the concept, believe me. And we understand why CMS wants to move there. However, we think it’s premature and very troublesome for us to make that switch. But it would be incredibly valuable for our members to be able to participate in QOPI and not have to participate in the CMS or PQRS system separately, which is really too skimpy on oncology measures.
OBR: You say you want oncologists to be one of the leading specialties in payment reform. Is that sort of representative of your group or is that also because of the unique delivery of care that puts oncologists in a different category than other specialties?
AL: Our desire to be forward thinking is due to a variety of factors. The nature of our specialty makes us data driven and interested in doing, if you will, clinical experiments to find out how we can do what we do better. I think that translates over into this work. I also think that the unique nature of what we do and the difficulty CMS has with getting payment formulas right, that is, to incent what needs to be incented, to compensate what needs to be compensated, needs to be done better. The field is changing as precision medicine comes of age, or the influx of oral cancer drugs. If I can use the analogy, oncology is the square peg that is trying to fit into the round hole CMS created 30 years ago. Some very good things can come out of having a chance to do a reset here and we feel very motivated to say, if things are going to change, we, the physicians in the field, want to lead that change, versus to wake up one day and get a letter from CMS that says “here’s your new payment system; we hope you have a nice day.”
OBR: The idea being to stay active and involved in order to determine your own fate rather than waiting for CMS to determine your fate.
AL: And then of course, we at ASCO will be moving ahead in 2014 on our big data project called CancerLinQ. Our design is to capture the electronic medical record encounter of as many medical oncology encounters as we possibly can get. We need to analyze the data so we can monitor quality far better than we have been able to do heretofore. And, we can also use the data to make our quality measures and performance measures even better and more precise. We believe along with most people in the field that having the most robust quality program that we can have is the underpinning of any new ability to generate a new payment model.
The new payment model provides incentives for quality, as most of them do, but there has to be some ability to measure that quality. If a payment model moves to more bundles or episodes where many services are grouped together under a single payment, there has to be a sense that the practice is providing the services as they should. All of this requires that we monitor and show what we’re doing. So we think CancerLinQ is a critical step in establishing standards, which new payment models can use to provide the assurance that things are being done correctly. Next year is the year that we will actually start building the full-scale project. This follows on the heels of our prototype project that we released early in 2013. It’s probably going to take us to 2015 to actually flip the switch, but we hope to begin to doing some of the formal testing of the system as it gets ready for its formal debut.
OBR: So you see CancerLinQ as a way of helping to measure quality. Do you think CancerLinQ has the capability to impact the clinical trial system?
AL: Clinical trials have been the bedrock in oncology for decades. We are the most clinically research-intensive field in all of medicine. If you look at any institutional review board and look at all the protocols that they’re evaluating and approving and monitoring, somewhere between 40% and 50% of their work is oncology, and the other part is all the rest of medicine. There are so many questions to answer that there’s just not enough money, time, energy, patients, to answer them. Secondly, the accrual into clinical trials has stagnated and even begun to drop. The NCI, under tremendous funding pressure, has had to cap the number of patients enrolled in the national cooperative groups. We are losing the ability to produce the knowledge as rapidly as we need to produce it. We’ve tried for so many years in my experience to attend meetings and conferences and workshops as to how we’re going to make the current system better, how we’re going to fix it, how we’re going to make it more efficient and so on and so forth, but in reality, we have to conclude that these very well considered and often creative efforts have in large part not moved the needle.
We have to begin to change the paradigm of how we can create new knowledge in oncology, faster, cheaper, and better than we’ve ever done it before. We will need a new system to do that. Part of that system is going to be based on the ability to collect treatment experiences and outcomes of those experiences from very large numbers of cases to learn from it in fairly formal ways. Now, I am not saying that we should stop doing randomized prospective clinical trials; they will always be with us. But we need to begin to add a very new way of gaining knowledge and that’s where CancerLinQ fits in.
OBR: Do you feel like you have to have a training session with all the oncologists out there about how to use their EMR so you get the data you need to make CancerLinQ effective? It seems fraught with challenges this early in the game, and while it may be routine four years from now, how do you avoid “garbage in, garbage out”?
AL: Well, “fraught with challenges” is what’s engraved on the front door of my office. We are tackling a huge problem and in some extent we are the first group that has at least publicly announced our intentions to do it. There’s a reason that no one else has done it before, and it’s because it’s not easy. As the head of the office of the National Coordinator for Health IT once said to me, “Allen, you’re not going to get sushi quality data right out of the gate.” It’s going to be imperfect at best, but it will improve over time.
OBR: You have to start somewhere, right?
AL: Exactly, it will improve over time and the quality of the data will get better. But if we wait until the quality of an EMR is perfect, we’ll wait forever. So you start: you analyze the data, you see where the holes are, and provide feedback to practices on what information is missing. The beauty of this is that oncology physicians are leading this program. This is not some big corporation out there, like Microsoft, saying here’s Windows and that’s the product. This is being designed, used, and analyzed by the oncology community itself, which is another reason this is so powerful. This is “us working with us” to make us better.
OBR: This year the NIH will award about 2,000 fewer grants. How is this affecting the community?
AL: The purchasing power of the NIH budget has dropped about 25% since 2003. It is a very difficult problem to watch, especially in oncology where we’ve started to unlock the door on precision molecular-based medicine; where we’re seeing almost an entirely new field of immunotherapy in cancer emerging, and the ability to analyze cancer genomics, which is exploding. At a time when the possibilities are increasing almost exponentially, NIH funding is decreasing.
What’s sad is to see scientists who have been funded for years and years, whose research started 10 or 15 years ago and now the research is ready to bear fruit and their funding is pulled. There’s just no reasonable way to defend actions like that. Francis Collins says it’s the most perilous time that he’s witnessed in his career and I think that’s saying a lot.
OBR: Well said. Any last words before we go?
AL: We intend to continue to make sure that the advocacy work that we do, and others do, on behalf of oncology is as data driven as possible. Two years ago, we started to create a census of all medical oncologists: where they are, where they practice, the size of their practice, and what are the things that they’re seeing in their community in terms of payment issues and merging with hospitals and acquiring other practices and consolidating and so forth. There’s a lot going on out there.
The more we know about where everybody is and what’s happening, the better we can understand the trends while they’re occurring, and at a time when there’s still a chance to influence them versus waking up one morning and recognizing that the landscape has changed so dramatically that you can’t recognize it. We will be publishing not only some individual pieces about this, but next spring we will be releasing a new publication called, “The State of Cancer Care in America” try to provide an annual snapshot of where the state of clinical cancer care is in the United States. It’s an important project for us and as I say, it will underpin our advocacy effort. There’s so much more I could talk to you about, but you’d have to write a whole separate article.