Nothing can bring potential adversaries together like having a common enemy. For payers and providers of healthcare, the scourge of rising healthcare costs demands that the two sides work together. And, when it comes to oncology, the threat of rising costs of care is unavoidable.
At the October 2012 Cancer Center Business Summit, held in Dallas, TX, Ira Klein, MD, MBA, FACP, Lead Oncology Strategist, and Chief of Staff to the chief medical officer, Aetna, and Lee Schwartzberg, MD, FACP, Medical Director, The West Clinic, Memphis, TN, discussed innovative programs among panels of peers at the Transitioning to Value Based Oncology: Strategies to Survive & Thrive symposium.
According to Klein, cancer costs have stuck out like a sore thumb. He says that as a cost category, “many employers have seen cancer rise from fourth or fifth expense to now being their first or second expense.”
The reasons for this rise are varied. Innovative drugs are expensive (whether they work or not) new imaging and radio-therapeutic technologies are also costly (whether or not their use is appropriate), and hospital rooms are shockingly expensive, regardless of the rationale for the stay.
This last point is one of the more troubling issues for Klein, who notes that the industry is currently in the throes of reform-driven consolidations, causing either the loss of many community oncology practices or the merging of practices with hospitals and what that entails. “We’ve noted a distinct tendency in people who work for these hospital systems to order more tests, and more pathology slides,” he says.
As a general (non-conspiratorial) defense, one could say that hospital-based providers are simply using more services because those services are more readily available. But according to Klein, “There’s an assumption—totally wrong of course—that when you aggregate services under one roof in this type of hospital system behemoth that you naturally get economies of scale, efficiency, and better coordination. Well, it’s simply not true.” To help control costs, and to keep oncology practices viable in the community setting, Aetna (a payer) has initiated a pilot program soon to be underway.
In Aetna’s pilot program, 50 community physicians from New York and New Jersey are to receive, free of charge, clinical-decision support software systems which will give practices that have no office software related to oncology a leg up, so to speak. The goal is to facilitate cost savings through streamlined ease of workflow and adherence to treatment guidelines. For example, one advantage being offered is an automated pre-certification process that promises to get a drug into a provider’s hands in a more timely fashion.
Other capabilities to streamline workflow are being offered through the Aetna-offered health information exchange portal, Medicity. The free, downloadable apps residing on Medicity can be used for a range of needs, from helping providers with referrals and consults, to offering a version of a Facebook-type app that allows the coordination of and communication with physician peers. “We believe that other insurers will see this and (want) to work with practices as well,” says Klein, “and that will form the basis for future pay-for-value contracts.”
This is not to say that Aetna is spearheading payment reform. “We don’t pretend to be able to tell CMS anything about what they do,” says Klein. Rather, Aetna is attempting to anticipate future payment adjustments by giving providers flexible tools that can rapidly adapt to changes in CMS payment methodology. Klein believes that without such tools community practices, which almost by definition operate on narrow margins, are too financially fragile to survive many current and upcoming payer demands. “There’s just no room for mistakes,” he notes.
Aetna is also working with software vendors that make clinical decision-making support tools in order to be able to accommodate Medicity interfacing with the larger EMR environment and with existing oncology EMRs. The idea is to make everything single entry with all data seamlessly populating all applications. “If you are in our New Jersey pilot program, and you want to use the Eviti software being offered along with your Altos Solutions EMR, we’re less than three months away from having that be a single-entry type of program. No double entering,” says Klein.
Interfacing with other systems will be key in coordinating costs, with accrued information being reported to the payer about the practice and the performance of its members being reported to the practice. Klein sees healthcare support systems as a boon to the healthcare conglomerations being created as a result of the Affordable Care Act. “And the whole thing is scalable. It really doesn’t cost more money to make these support systems available to a large number of players,” he says.
According to Klein, the ability to have tools that improve the quality of care and normalize cost—making it more predictable—is a godsend for ACOs “because cancer patients are not big in number.” ACOs only work when risk can be predicted, and cancer patients tend to defy actuarial predictions.
On the other side of the cost-containment coin, practices are also implementing programs to help control the rising costs of cancer treatments. “If practices do not pay attention to cost reform it’s going to be dictated to them,” said Lee Schwartzberg in his panel participation of providers.
The West Clinic approach to controlling costs is by pathways implementation. Pathway projects have thus far been created for most of the common cancers (breast, lung, colon, etc.) and are further delineated by their stage and by biologic subgroup. The West Clinic has pilot pathway projects with a couple of payers and, according to Schwartzberg, the programs generally coalesce around using more state-of-the-art approaches to patient care.
The content and flow of the pathways project was dictated by a few initiatives, including previous experience at West, NCCN guidelines, and input from Blue Cross of Tennessee, one of the payer partners. “Blue Cross didn’t have any direct involvement in crafting the pathways,” assures Schwartzberg, “but together we’re working on monitoring metrics of compliance.”
Should there be any confusion with the nomenclature, Schwartzberg points out the difference between a pathway and a guideline, by stating that, “a pathway is more encompassing,” he says. “Ultimately, a pathway should include everything that goes along with taking care of the patient at that stage of their disease. Not just the chemotherapy, but where radiotherapy is important, where palliative care fits in, where other supportive measures fit in, and labs and imaging as well.” The pathways implemented by West thus far lack such comprehension, but that is for lack of maturity rather than intent. “The build out is a future goal,” he indicates.
For instance, West is well underway in adding molecular testing to its pathways programs, such as the use of ALK mutation testing in lung cancer. That said, some molecular testing is already in place, such as EGFR (in lung) and HER2 and ER testing in breast cancer.
Regarding treatment, Schwartzberg affirms that the intention of pathways is not to prohibit choice. A doctor can choose a non-priority regimen, “and 20%-25% of the time that is done,” he admits. So the biggest challenge has not been providers chaffing at being told what to do, but aligning pathway recommendations with existing EMR protocols. “We’ve had so many regimens in our EMR—it’s weeding them out and cleaning them up, and renaming everything,” he says.
Would third party software (provided by, say, Aetna) be of any help with the integration? “It might be welcome,” Schwartzberg offers, “but it really depends on how much it interferes with the workflow of the clinic. If it runs in the background, it would be welcome.”
Once all the practice-related software programs are able to talk to each other, the next challenge will be keeping recommendations current while remaining economical. West will have to account for new data as it comes up, says Schwartzberg, as well as adjusting procedures as new payers come on board. “We don’t have just one payer, we have five.” If the information has to be delivered in five different ways that’s an added expense in time and money.
West’s pathways initiative is being monitored for compliance both at the individual physician level and at the overall clinic level. The target is 80%, and according Schwartzberg, West is achieving that target. Pathway data to date are also being mined for how pathways are being used, such as determining which regimens are most preferred in a given disease setting.
Going forward, Schwartzberg will use the data from Year One to streamline the options available, so that treatment choices are optimized in Year Two.
West’s focus over time is to narrow down, not necessarily to one treatment regimen, but to a small group of choices which makes it easier for the nurses, and more predicable in terms of the education that is required to safely and efficient use each regimen.
With proactive initiatives such as pathways, Schwartzberg is determined to stay ahead of the healthcare reform curve. And perhaps with the West Clinic’s experience as an example, and Aetna’s offer to lend a hand, bringing sanity to oncology care costs does not have to mean the demise of the community oncologist.