OBR Daily Commentary

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Community Oncology Alliance (COA) Payment Reform Brief Details 35 Oncology Payment Models Underway or Planned Across Country

(COA) Oct 15, 2020 - The Community Oncology Alliance (COA) announced today the release of its inaugural 2020 Payment Reform Brief, providing a unique look at community oncology payment reform trends at both the national and state levels. The COA Payment Reform Brief shows that there are 35 oncology payment reform models in 37 states, with seven models in more than one state, and four models operating nationally. Arizona, Colorado, Florida, and Ohio each lead the way with seven reform models. In 2019, when COA last inventoried oncology reform models, there were only 19 that could be identified.

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William McGivney, PhD (Posted: October 27, 2020)

quotesCOA leaders clearly are among the elite as experts nationally in the understanding and design of payment methods and models for oncology. To me, though, to have 35 different payment models in 37 different states with each one being “unique” and tailored to specific patient and payer needs is disappointing and befuddling. And, I know COA is dedicated to this, but how about payment models that are “unique” in their being tailored to meet physician needs and I use and emphatically emphasize the word “physician” and not the word “provider”. I think the most significant and substantial change and improvement in payment systems over the past 30 years has been the basing of coverage policy upon sound, scientific clinical evidence. This evidence-based process is not without flaws but it is a concept consistently and almost universally adopted by all Stakeholders in the cancer care delivery system. Strategically, having 35 different payment models could actually be a pluralistic ploy to obscure any one payment system from distinguishing itself and dominating. I need to stop here and read the full COA report in order to learn and better understand. I will write back!quotes

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Offering a Pay-for-Performance Program to Oncology Practices Increases Prescriptions of Evidence-based Cancer Drugs

(Penn Medicine) Oct 7, 2020 - A pay-for performance program that offers enhanced reimbursement to oncology practices for prescribing high-quality, evidence-based cancer drugs increased use of these drugs without significantly changing total spending on care, Penn Medicine researchers report in a new study published online today in the Journal of Clinical Oncology. This is the first study to demonstrate how a national insurer’s voluntary pay-for-performance program can successfully change prescribing patterns among oncologists to deliver higher-quality cancer care.

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William McGivney, PhD (Posted: October 08, 2020)

quotes It is always moderately entertaining to read the press releases associated with economic/health policy studies, especially when a “Medical Ethics” perspective is front and center in summarizing the study and its possible applications. In the present example, the bottom-line results of the highlighted insurance company Pay for Performance program as published in the Oct 7 issue of the Journal of Clinical Oncology are: 1. Increase in “evidence-based” prescribing by 5.1% up to 62.2%; 2. Increase in cancer drug spending by $3,339 to $51,369 per patient = 7% increase 3. Increase in patient-out-of-pocket spending by $253 to $2470 (11.4%) “a small but statistically significant amount”. Sounds like just what an insurance company exec would want to hear as the results of a much-criticized, much-maligned program seeking to substantially circumscribe the therapeutic options of medical oncologists. After four years, the program pushed up evidence-based (whose evidence-based?) prescribing by 5.1%. But for example, the PD-1/PD-L1 choice in NSCLC was limited to one PD-1, a truly effective biologic, but there certainly are others. Accompanying that 5.1% increase vis a vis the limited options made available, was a 7% increase in cancer drug spending. And for patients, as the quote says, “a small but statistically significant amount” for the 11.4% increase (i.e., $253) in patient out-of-pocket spending. Ouch, on that statistically significant amount. An 11.4% increase characterized as “small”! Raises in Medical Ethics departments must be pretty good these days and probably with a lot less stress than most of us experience. In the press release, a concluding quote reads: “This program is a much-needed example of an effective program - one that improved the quality of care for patients. As we look forward, we need to build on the success of this program to design programs that also decrease costs.” Sounds like a grant proposal will be forthcoming! Reminds me of another story from years and years ago when I was asked to review a grant proposal for over $400k to understand how coverage decisions were made. I was at Aetna at the time; my recommendation on the grant proposal was “Call me, we can talk for an hour for free, I will explain, you can save a lot of money”. Of course, I was never asked by that well-known agency to review another grant proposal again! By the way, I never saw any specific Quality of Care results in this published article; I guess those such results are alluded to only in the Press Release! One final note is that the Advisor Medical Oncologists are never named only their affiliated institution. I wonder how happy the named institutions would be to have to abide by the drugs/biologics regimens specified in the “Evidence-based" Program? Anybody ever hear of the NCCN? quotes

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Executive Order Would Tie U.S. Drug Prices to What Other Countries Pay

(ASCO In Action) Sept 15, 2020 - On September 13, President Trump signed an executive order (EO) aiming to address high prescription drug prices by tying payments for certain Medicare drugs to the costs the treatments sell for outside the United States (U.S.).

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William McGivney, PhD (Posted: September 28, 2020)

quotesClearly, there is general agreement on the fact that many drugs and biologics for cancer treatment are too expensive. Examples of this include the present ASCO statement of concern and a statement contained in an Aug 27 release by the Community Oncology Alliance. An equitable fix requires that patients’ interests be first and foremost. However, patients’ interests for access to an ever-improving armamentarium of drugs and biologics are inextricably dependent on both a healthy, profitable biopharma industry and a healthy, financially-sound provider delivery system. The needed solution may indeed eventually have to be dictated by the White House or some other authority in Washington DC. What that solution might be is indeed incredibly difficult. As I moderated a session in the fall of 2019, I was surprised to hear a KOL insurer opine that he/she did not think that an International Pricing Index-derived price based almost exclusively on prices “allowed” by European government insurers would be sufficient for to maintain needed levels of access, prescribing and innovation in the United States. At present, it has been argued by many (organizations and individuals) that now is the worst of all times and timing for this Executive Order to have been released. The exigencies of fulfilling electoral promises and of the pricing issue itself meet the deleterious impacts of the COVID pandemic with patients delaying care in Oncology; hospitals and practices finally seeing more and more of those patients who need to be diagnosed, treated and monitored; hospitals and practices financially hurting from revenue shortfalls caused by the pandemic; etc. So, the “ball” will now be lateraled over to the CMMI Innovation Center to innovate a reasonable solution to be evaluated under traditional demonstration program rules. Organizations already are demanding that any demonstration project not require the mandatory participation of oncologists; the project should be voluntary. One would expect a relatively measured approach by CMMI as the CMMI folks will be anxiously awaiting to see which Party will reside in the White House for the next 4 years and, thus, drive the pricing agenda and activities. As such, the Executive Order will cause a timeout to be taken as this long-running pricing policy stalemate waits for Overtime. quotes

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Meet the Editorial Board

Prostate Cancer
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Tomasz M. Beer, MD, FACP

Professor of Medicine, Division of Hematology/Medical O...

Community Oncology
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Dean Gesme, MD

FACP FACPE FASCO President, Minnesota Oncology...

Breast Cancer
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Debu Tripathy, MD

Professor and Chair, Department of Breast Medical Oncol...

Lung Cancer
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H. Jack West, MD

Associate Clinical Professor, Medical Oncology Executi...

Gastrointestinal Cancers
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Howard S. Hochster, MD

Distinguished Professor of Medicine, Rutgers Robert Woo...

Radiation Oncology
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Howard Sandler, MD, MS, FASTRO

Ronald H. Bloom Chair in Cancer Therapeutics Professo...

Editor-In-Chief
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Robert A. Figlin, MD., FACP

Steven Spielberg Family Chair in Hematology Oncology P...

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Stephen M. Schleicher, M.D., MBA

Community Oncology, Medical Oncologist, OneOncology...

Health Policy
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Ted Okon

Executive Director Community Oncology Alliance...

Community Oncology
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Thomas Marsland, MD

Vice President Integrated Community Oncology Network ...

Health Policy
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William McGivney, PhD

National Health Policy Expert...