As the COVID-19 pandemic continues to make an impact across the country, The US Oncology Network is committed to ensuring that community oncology practices have the resources and tools necessary to navigate this crisis. Through telemedicine support, IT, human resources, best practice sharing and communications we are committed to supporting practices to ensure they can continue to care for their patients during these unprecedented times.
We are diligently working on innovative strategies to support practices and their teams. Our COVID-19 task force continually monitors and evaluates to situation. Our decisions are based on recommendations from the Centers for Disease Control and Prevention (CDC), the American Society of Clinical Oncology (ASCO) and other federal, state and local agencies.
Communication with practices and patients
We have prioritized communication with The Network to ensure practices have the most up-to-date information. Weekly meetings with practice leadership and physicians are in place to provide updates and a forum to share ideas and collaborate. In addition, communication guides and templates help practices communicate with patients, staff and the media during this crisis.
To help providers communicate with their patients, we quickly launched a telemedicine solution that allows patients to continue to receive care without having to leave their home. With relaxed regulations around telehealth during this time, visits are covered by payers making it an alternative to visiting the clinic. Since the launch of the telemedicine solution, practices in The Network have had more than 6,000 visits across nearly 1,200 providers.
Breaking down federal and state relief bills for community oncology practices
Our government relations and public policy team is helping practices break down and understand federal and state level COVID-19 legislation such as the Coronavirus Preparedness and Response Supplemental Appropriations Act, Families First Coronavirus Response Act, and Coronavirus Aid, Relief and Economic Security (CARES) Act. Through webinars and summary documents, The Network practices learn about the impact of these bills on their practices and patients quickly. The latest information on The Network’s advocacy efforts, federal support for physician practices, executive orders, and legislation in response to COVID-19 is available on Legislink.com.
During this time, it’s paramount that practices have access to tools and resources necessary to deliver care to cancer patients. Providing those resources and support is our top priority now in a time of crisis and into the future.
Proton therapy is an advanced radiation therapy that uses protons to treat cancer rather than x-rays. Protons deliver the majority of their energy directly into the tumor and stop, minimizing exposure to adjacent healthy tissue. X-rays used in standard radiotherapy continue through the tumor, exposing patients to unnecessary radiation that can result in both short-and long-term side effects and secondary tumors.
Proton therapy was approved for cancer treatment in 1988, but was not commonly used due to the high cost of developing proton centers. Development costs have been greatly reduced, and today there are 29 centers across the country. The technology is evolving as more research is conducted and we discover more and better ways to use the therapy. During my several decades of working with proton therapy, I have had the opportunity to play a role in some of the advancements that have occurred. One such development that holds great potential for cancer treatment is pencil-beam scanning. This technology provides greater conformality in tumor treatments compared to traditional proton beam therapy, enabling us to treat patients today that we previously had to turn away. In spite of the promising advancements being made and the decreased development costs, proton therapy remains controversial because treatment costs are higher than conventional radiotherapy.
A closer look at the benefits
Critics often contend there is little evidence to support the cost of proton therapy, but there are many credible clinical studies that show substantial benefits to patients. Additionally, when considering the value of proton therapy, there is more to examine than just the initial cost of treatment. Ongoing expenditures for treating side effects, as well as the patient’s quality of life, must be considered. Managing toxicities, both short-and long-term, is expensive and can be a financial burden to patients and other stakeholders. Patients also want the best quality of life possible so they can enjoy their survival. Proton therapy addresses both of these concerns, minimizing costly side effects while improving quality of life.
Another issue to consider is that lifespans are increasing and many patients are living several decades beyond their treatment. During that time, many experience another episode of cancer. Approximately one in 12 adults diagnosed with a common cancer will eventually develop a second cancer unrelated to the first.1 Patients eventually reach a point where they cannot tolerate any more treatment in their lifetime, so managing the second cancer becomes problematic. Proton therapy can control the initial cancer while minimizing treatment toxicities, offering an avenue to more effectively treat a second cancer if one occurs.
Finally, as more cancers are cured, we will have many more survivors. The increasing number of these patients and the potential costs of treating side effects on a larger scale will dramatically impact our limited healthcare resources. It will be essential to minimize the consequences of cancer treatment while still supporting optimal outcomes. Proton therapy can play a vital role in achieving that objective.
Investing in optimal outcomes and quality of life
While we are all concerned about costs, we shouldn’t invalidate a treatment that may initially be more expensive but can provide substantial cost savings, improved outcomes and a better quality of life in the long run. It is time to recognize the many benefits proton therapy provides over the long-term, rather than just focusing on the here and now.
1. https://www.medscape.com/viewarticle/866433
Approximately 90% of oncology patients require a complete blood count (CBC) when they visit their oncologist for the first time. The CBC is used to evaluate a patient’s overall health and detect a wide range of disorders, including anemia, infection and leukemia.1 The test is especially critical in oncology, where cell counts can help guide important and time-sensitive treatment decisions, including whether to start or stop chemotherapy, identify if a patient needs a blood transfusion, or to make sure a patient’s bone marrow is functioning properly. In fact, nearly 70% of clinical decisions, including diagnosis and treatment, are based on CBC results.2
On-site lab allows for convenience and speed
For patients, an appointment with an oncologist can be daunting and stressful. To alleviate some of the stress, offering a “one-stop-shop” where patients can meet with their physician and also get bloodwork done in a matter of minutes allows for a more convenient and positive patient experience where important treatment decisions can be made on the spot. Without an on-site lab, patients are required make several stops, wait for results, and only then can they follow up with their oncologist – taking more time than necessary.
Key benefits of on-site labs
In addition to speed and convenience, on-site labs offer five key benefits:
- Direct supervision over quality and cost decreases operating expenses.
- Less pre-analytical handling of blood specimens reduces errors that can cause inaccurate results.
- Follow-up testing can be easily added to an existing blood sample without having to redraw.
- Consistent reference ranges mean decreased interpretation errors.
- Many research clinical trials require pre- and post-dosage test results.
There are approximately 250 on-site labs in practices across The Network, and each lab is equipped with top-of-the-line clinical laboratory services. Lab test menus vary in complexity from CBCs to Flow Cytometry and other esoteric testing.
On-site labs play a vital role in value-based care
The Network helps practices achieve significant and measurable cost savings for on-site labs. Savings are partially realized through low standard pricing for equipment and reagents, which ultimately reduce overhead costs by decreasing internal cost. This is critical as the health care landscape shifts to value-based medicine and adopts a model of payment for a treatment, rather than for an individual visit or service.
The US Oncology Network Laboratory Team is currently working on several initiatives to support affiliated practices, including recent updates to administrative and regulatory standards, all of which are readily available for practices through an internal portal.
Given the importance of lab testing to a patient’s treatment plan and outcome, having an on-site lab in today’s health care landscape benefits physicians, patients and payers.
1. https://www.mayoclinic.org/tests-procedures/complete-blood-count/about/p…
2. https://www.mayo.edu/mayo-clinic-school-of-health-sciences/careers/labor…
By Marcus Neubauer, MD | July 2018
Since July of 2016, roughly 187 oncology practices across the country have been participating in the Oncology Care Model (OCM), the Center for Medicare & Medicaid Innovation’s (CMMI) new program designed to reduce the cost of care while improving quality and patient outcomes. Sixteen practices in The US Oncology Network (The Network) are participating in this care delivery/payment model, providing enhanced care to thousands of Medicare patients.
The Oncology Care Model is a very complex program, and there is a definite learning curve for practices trying to implement it. From input gathered so far across The Network, as well as from my own experience with the OCM, there are some critical activities that must be performed well to ensure success with the program.
Key Activities when Participating in the OCM
Initially, practices must determine which patients are qualified for the program. Identifying patients is challenging, especially those patients who are only on oral drugs, and workflow changes within the practice must be implemented to pinpoint eligible patients. Once patients are enrolled, practices must then bill for the monthly-enhanced oncology services (MEOS) CMS pays to fund the program. New processes and procedures will be needed to ensure all MEOS payments are billed and collected to support the special services being provided.
MEOS payments must be utilized to fund the enhanced care practices are required to deliver according to terms of the program, rather than being used for other purposes. Medicare refers to this as appropriate cost resource utilization. Data must be submitted to verify how the money is being spent, including information about new hires that are critical to the OCM, as well current employees who are spending time on the program.
Performing well on all quality metrics and reporting the data are key activities of the OCM. Practices must report their performance data through the OCM portal, submitting detailed information about each enrolled patient. Practice performance is also judged on quality measures drawn from CMS claims data. The quality measure relating to the practice’s ability to keep patients out of the hospital is critically important, and practices must excel on this metric to succeed with the program.
Practices must also pass inspections by CMS and be prepared for close-up scrutiny. The agency may conduct on-site visits and detailed audits to ensure program rules are being followed. Many of the OCM requirements are designed to drive and support optimal outcomes, so it is critical for the practice to adhere to terms of the program. Practices that do not meet all requirements may be removed from the OCM, even if they are performing well in other areas.
Appropriately managing and reducing the cost of care is undoubtedly the most crucial activity that must be done well, as controlling costs is a major goal. The program is under close observation by CMS and CMMI to evaluate whether or not the model design can drive better care and outcomes at a reduced cost. Practices that have high performance scores in other metrics but report exorbitant costs will not succeed.
Activities help practices transition to value-based care
Excelling in these key activities can help ensure success in the OCM, while also providing a strong foundation for value-based care, overall. While the OCM is a five-year pilot project ending in 2021, value-based cancer care is not going away. The government is focused on driving value in healthcare, so programs like the OCM will only become more commonplace. To thrive in this new environment, practices must adapt by transforming their organizations to meet the needs of this new way of delivering care.
By David C. Fryefield, MD | June 2018
Radiation oncologists have been operating in a very challenging landscape for quite some time―one that has created unpredictable revenue streams for providers and made the delivery of quality care more difficult. Providers are under pressure from payers to reduce the number of treatments based on clinical trials demonstrating fewer treatments are as effective as a larger number in certain cancers. Innovative technologies are now part of the radiation oncologist’s toolkit, but these advances are driving up costs. As a result, prior authorization requirements and denials have greatly increased, dramatically impacting revenue and hindering the timely delivery of quality care.
New Payment Models Reduce Uncertainties
To drive greater value in cancer care and provide more predictability to providers, payers and patients, The US Oncology Network (The Network) has developed several alternative payment models (APMs) for radiation services. These new value-based APMs focus on private payers, since roughly half of a practice’s patients may be covered by private or commercial insurers. While reducing the uncertainties around treatment authorizations and reimbursement, these APMs also more closely align payments with the care patients actually receive.
Several practices in The Network already had APMs up and running while our models were on the drawing board, providing valuable insight into how various APMs actually perform. Drawing from this hands-on experience and the collective expertise and resources of The Network, two APM models were created, both of which transition from the traditional fee-for-service model to more predictable episode-based bundles.
The Episode of Care Model
The episode of care model offers flexibility, as it can be designed either as a disease site/stage-based model or a modality-based platform. The disease site/stage-based framework provides prepayment for a defined single episode of care based on the disease site or stage. The modality-based model provides prospective payment for an episode of care utilizing case rates based on various technologies, including 3D conformal therapy, IMRT, SRS/SBRT, and HDR/LDR brachytherapy.
The Capitated Payment Model
Less prevalent across The Network with practices already using APMs, the capitated model shifts more risk to providers for patient care, paying them on a per member monthly basis for services provided to a specific payer population.
There is a definite learning curve when implementing these new models, and The Network is assisting affiliated practices with various levels of support. A comprehensive playbook has been developed to guide practices in determining which models are the best fit for their practice. Risk mitigation strategies are also presented, along with information on evaluating APM opportunities and the readiness of the practice to implement the new models. Ongoing assistance is also provided to help practices succeed as they encounter challenges along the way.
Creating Our Own Future
While we cannot control the evolving environment we currently operate in, we can control how we respond to it. Value-based care is here to stay. Consequently, we have much to gain by developing our own value-based models that better serve all stakeholders, rather than waiting for less than optimal models to be forced upon us. While it is too early to draw definite conclusions about whether these new APMs will be successful, they are, nevertheless, a great start on our journey to value-based care for radiation services. Not only do they support the timely delivery of high-quality care and realign incentives in a more equitable way, they also provide valuable real-world experience that can drive improvements in future models.
Those of us in the cancer community know that progress in the fight against cancer is often measured in very small steps. Certainly since I finished my fellowship, that has been the case. Over the last 30 years, treatment for many deadly cancers has usually involved substituting one chemotherapy drug for another, buying a patient time while increasing the cure rate by a mere percentage point or two.
However, cancer research has finally taken a giant leap forward with a powerful new immunotherapy, chimeric antigen receptor (CAR) T-cell therapy. This exciting new therapy has demonstrated phenomenal results for certain hematologic cancers, while offering the promise of better outcomes for many other cancers in the future. Patients previously considered terminal are now in remission with good quality of life demonstrated for up to five years.1 Many of these patients look like they are going to be cured, as survival curves plateau after two years. The therapy is currently approved for use in relapsed diffuse large B-cell lymphoma (DLBCL), and pediatric acute lymphoblastic leukemia.
The treatment is quite complex. Thousands of the patient’s T-cells, a type of lymphocyte, are extracted from the patient’s blood. The cells are then reengineered in a laboratory using a viral vector, transforming them into cells that attack the CD19 antigen in cancer cells. Millions of these genetically modified cells are then produced in a laboratory. After undergoing lymphodepleting therapy, the programmed lymphocytes are then infused back into the patient. CAR T-cell therapy is often referred to as a “living immunotherapy” because the cells continue to multiply on their own, taking up to three months to reach maximum response.
Centers offering the therapy must be certificated and staff must receive special training to ensure they understand how to administer the therapy and identify and manage possible side effects, which can rapidly become life threatening if not treated promptly.
Bringing CAR T-Cell therapy to local communities
The US Oncology Network (The Network) is very excited about this promising therapy, and presently several practices in The Network are investing in the extensive training required to offer this innovative treatment. The Network is also working with CAR T-cell manufacturers to participate in the next clinical trials. The first such trial is for patients with relapsed DLBCL who are not candidates for an autologous stem cell transplant. The participants will be over age 70 or have other comorbidities. We hope this will be a very promising treatment option for these patients who are not considered fit enough for a transplant, which previously was the only proven curative therapy.
Presently CAR T-cell therapy is only available in a few centers around the country, many of which have waiting lists. Unfortunately, many patients simply cannot endure the burdens that traveling for treatment often present, so they have no access to this lifesaving therapy. The goal of The Network is to dramatically increase accessibility, bringing CAR T to selected practices in local communities so patients can be treated close to home.
CAR T is a very exciting development that is rapidly changing the treatment landscape. Before giving up on a patient, I encourage all physicians not familiar with CAR T to check with a CAR T treatment center to see if it is appropriate for their patient, as today there is new hope where before there was none.
1 https://www.cancer.gov/about-cancer/treatment/research/car-t-cells
Community oncology practices today face an increasingly complex web of government rules and regulations that can often inhibit practice success or viability. This complexity is having a direct impact on access to quality cancer care. Eleven years ago, when I began my journey with The US Oncology Network (The Network), nearly 88% of all cancer care was delivered in the outpatient community setting. Today that figure is closer to 50%. This migration away from the community setting has a measurable impact on the healthcare ecosystem as hospital care is much more expensive for patients and payers. Conversely, helping community practices flourish is beneficial not only to patients and independent providers, but also to other key stakeholders in the cancer community. In today’s “value-driven” environment, it doesn’t make sense to continue enacting rules and regulations that accelerate this shift to the more expensive, less coordinated setting.
The Network Government Relations Team Is Hard at Work Protecting Community Cancer Care
Not only does The Network provide services and technologies to enhance clinical and business operations for practices, we also advocate on behalf of community oncology on the federal, state and regulatory levels. Our Government Relations and Public Policy Department is dedicated to federal policy issues and state legislative matters. The team combines years of Capitol Hill experience with a deep and diverse healthcare policy background. Our primary mission as thought leaders is to craft new policies that benefit community oncology or analyze proposed policies to determine what impact it could have on practices in The Network. We then formulate a strategy and respond appropriately on behalf of the practices, often engaging them directly.
We also act as the voice of The Network when the Centers for Medicare & Medicaid Services (CMS) roll out regulations and payment rules, evaluating each proposal, submitting formal comments to CMS and following up with meetings. This year, we assisted in drafting formal comments on four separate federal rules which were submitted on behalf of The Network’s physician led National Policy Board. These comments covered a wide range of topics including provider rates, consolidation, pharmacy coverage, radiation therapy and the 340B drug discount program. You can stay up to date on our efforts by visiting legislink.com.
Practices can look to us for support in the public policy arena, such as:
- Legislative and policy insight – from the moment an issue is first conceived until it is defeated or enacted
- Arranging for physicians to directly engage with key decision makers to make their voice heard
- Assisting physicians in testifying before Congress or state legislatures on behalf of The Network
- Coordinating site visits to practices for members of Congress, giving them a firsthand look at the challenges practices face, and
- Managing The Network Political Action Committee (PAC) comprised solely of physicians and leaders in The Network, in a bipartisan effort to support legislators who support community cancer care
Make Your Voice Heard
Our goal is to help influence public policy by effectively strategizing, advocating and educating to ensure decision makers truly understand the impact of what they are putting into law. It is vitally important for practices to regularly engage with their local elected officials when things are going right, so their opinions will be respected when things go awry.
The Network public policy team can play a key role in helping practices develop and execute a thoughtful, multifaceted strategy that positions them as thought leaders and problem solvers in today’s challenging environment.
Oncology is dramatically different today than when I entered the field 12 years ago. Practices are experiencing seismic changes in their environment and facing complex issues not previously encountered. While we cannot control the volatile landscape, strategic planning enables practices to prepare for what is coming, to take advantage of opportunities, and to set a direction for the practice that will position them for success.
Building a roadmap to the future
The US Oncology Network (The Network) wants its physicians to do more than just survive. We want them to thrive in our ever-changing world. We place a strong focus on strategic planning by providing structured guidance and access to a wealth of valuable data to aid in decision-making. Our strategic planning process is a team effort that marries resources from the local and corporate levels to provide the most comprehensive package of information, tools, and expertise available. Our model enables us to develop plans to guide practices on their chosen path for three to five years, including detailed, annual action plans to execute on the practice’s overall priorities.
Day-long retreats are held, with planning starting six months in advance. Three months before each retreat, I meet individually with physician leadership and key management team members, gathering input on practice background, overarching concerns, potential strategic opportunities, and other information that helps us build a solid framework for the retreat. A joint committee is formed that is responsible for preparing the intellectual infrastructure. The Executive Director (ED) is intimately involved, as are other appropriate team members. Weekly team calls are held, and we collaborate to develop comprehensive material on market analytics, finance, business development, managed care and other significant topics. The information is extremely detailed, empowering leadership to make informed decisions.
Our goal during the retreat is to build consensus among the practice physicians and leadership on three to four strategic priorities. Action plans for the first three years are developed for each priority, including a very detailed plan for the first year, as well as a list of staff responsible for various tasks. The regional senior vice president (RSVP) and the ED lead the practice in executing the plans.
Strategic planning is a process that never ends. Each year we revisit the plan to determine if it is still valid, if it needs to be tweaked, or if we need to go back to the drawing board.
Bringing the plan to life
A practice can have the greatest plan in the world, but if there is no structure to ensure action, nothing happens. Following are a few best practices for executing a plan:
- Set realistic timelines
Physician and staff time is limited. Initiatives may have to be prioritized one after the other to ensure proper execution. Dedicate necessary resources.
- Financial resources will need to be budgeted and dedicated (when applicable).
- Stick to the plan
Carefully consider any new ideas that are brought up after the plan is in place. Unless the idea is consistent with the chosen priorities, stay focused on the approved plan and save new ideas for a future plan revision.
Thrive, rather than just survive, with strategic planning
Successful oncology practices will navigate the evolving landscape with a well-thought-out roadmap to guide them on their journey. An old African proverb sums it up perfectly: “Tomorrow belongs to the people who prepare for it today.”
Advanced Practice Providers (APPs) play a vital role in supporting practices across The US Oncology Network (The Network) delivering high quality care to patients. APPs are healthcare providers, including Nurse Practitioners and Physician Assistants, who have advanced education and are licensed in the state where they practice, and certified nationally. In oncology, these highly trained professionals work collaboratively with physicians, expanding and enhancing the care physicians provide patients.
The Network APP Program
Since joining The Network in 2015, I have seen substantial growth in our APP program. We now have nearly 400 of these highly skilled professionals working in a variety of specialties in nearly every practice across The Network. Most work in medical oncology, but we have growing numbers in surgical subspecialties and radiation oncology.
The overarching mission of APPs in The Network is to allow practices to see a high volume of patients while continuing to deliver quality care to everyone.
In The Network practices, APPs are a vital part of the care team and play a critical role in many different areas, including: follow-up clinic visits, hospital rounds, chemotherapy and symptom management education, monitoring oral therapy patients, research, genetic counseling, and surgery. APPs also introduce and manage advance care planning and survivorship programs to patients, programs that are a major emphasis within The Network and key components of the Oncology Care Model. Additionally, APPs enable patients with urgent, or acute care, needs access to same day appointments, helping them avoid emergency room visits or hospitalization.
Supporting our APPs
Community oncology can be overwhelming, particularly to new APPs who are managing a variety of co-morbidities while trying to stay current on various drugs and treatment guidelines. To help our new APPs get off to a strong start, we offer an intensive orientation on-boarding course three times a year. In addition to learning about current clinical oncologic topics, attendees have the opportunity to network with their peers and develop mentorships.
We are working with the American Society of Clinical Oncology (ASCO), the Advanced Practitioner Society for Hematology and Oncology (APSHO) and other organizations to develop a comprehensive skills assessment APPs can take every few years to identify areas for personalized learning. We have developed an APP Leadership Academy for current and future APP leaders and expect to enroll the first pilot group this spring. We work to ensure every APP, from the new graduate to the seasoned clinician, has access to the support and educational opportunities they need to grow and succeed.
In addition, we have many resources to help practices properly utilize APPs. Our valuation models show the financial value, as well as the non-billable benefits, that APPs bring to a practice, helping practices understand the tremendous contribution APPs can make to their organization.
An expanding role for APPS
As value-based cancer care continues to evolve, APPs will become increasingly important. Value-based care―especially the Oncology Care Model―emphasizes reducing costly hospitalization and emergency room visits. APPs can help practices accomplish this by providing patient education, symptom management and access to care when needed. Advance care planning and survivorship are also highlighted in value-based models, and APPs do exceedingly well with leading these important programs. In the future, we will likely see many more bundled payment models, creating a huge opportunity for APPs.
Over the last couple of years, I have seen greater acceptance and improved utilization of APPs across The Network. We will continue to build on this success by expanding into subspecialties, particularly radiation oncology and surgery, and by developing innovative programs and initiatives that help our APPs grow and succeed while finding satisfaction in the important work they do. Our goal is to be recognized as the premiere employer of APPs.
By Barry Brooks, MD | January 2018
To remain strong and viable in today’s evolving healthcare landscape, practices must continually forge new relationships, embrace innovative tools and technologies, and seek more efficient ways of doing business and delivering care.
One of the most important developments I have seen over my career is the growing importance of group purchasing organizations (GPOs) and the increasing value they provide to community oncology. A GPO is an independent organization that contracts with pharmaceutical and biotechnology manufacturers to obtain discounted pricing on drugs and services on behalf of its membership.
Unity GPO: The leader in community oncology
GPOs are advantageous to community oncology because practices that aggregate into a large group can obtain better drug prices, and access to other services and technologies that support efficiencies and quality care. Those of us in The US Oncology Network are fortunate to have access to the best GPO in the community oncology market, Unity GPO. Over the last decade, Unity has evolved into the most efficient GPO in the community oncology space when measured against other differentiated contracts in the market.
As Unity GPO’s contracting physician lead since 2005, it is rewarding to see the ongoing contribution the organization makes to The Network. Thanks to their longstanding relationships with some of the largest pharmaceutical manufacturers in the nation, Unity GPO delivers a level of savings on drugs and services to our practices that is unparalleled in the market.
Key stakeholders benefit from the GPO
Through Unity GPO, we are able to negotiate better prices for the buy and bill model we use in our practices, allowing us to provide cost-effective, high-quality care that benefits patients, providers and payers, as well as pharmaceutical manufacturers who have made significant investments in cutting-edge therapies. Because The US Oncology Network is comprised of physicians who share a standard practice model and a common culture built around clinical pathways that have been developed in partnership with the National Comprehensive Cancer Network (NCCN), we are able to easily alter our prescribing habits across The Network to leverage our Unity contracts. By using therapeutic interchanges at the practice level, one product in a class can be substituted for another therapeutically equivalent option that allows us to quickly embrace the preferred pricing obtained through Unity GPO.
By having better prices and better margins on the drugs we prescribe, we can help reduce our patients’ co-insurance burden while improving the financials of the practice at the same time. Pharmaceutical manufacturers also benefit as this preferred pricing encourages our practices to adopt new therapies ahead of national trends, often exceeding sales expectations. This performance on preferred contracts encourages manufacturers to continue giving us favored economics in the future.
GPOs play a vital role in value-based care
When The Network first became involved with value-based care, I did not anticipate the crucial role Unity GPO would play in our success with these new models. Over the last few years, the importance of our GPO has dramatically risen based on our experiences with the Oncology Care Model, Medicare’s value-based reimbursement program, as well as various value-based commercial contracts. The biggest opportunity in these models to lower cost of care for both patients and payers is mainly in the medication and drug space. Consequently, our affiliation with Unity GPO has turned out to be a huge asset as oncology transitions to more value-based contracting with payers.
For practices in The US Oncology Network, Unity GPO empowers us to deliver affordable, high quality cancer care in local communities where patients live and work and have the support of family and friends. This local care helps patients obtain optimal outcomes while having the best possible experience during their cancer journey, something all of us in cancer care strive to achieve for the many patients who entrust their care to us.
By Diana Verrilli | November, 2017
Over the last several years, many promising new cancer therapies have come to the forefront. The pipeline of new cancer drugs has never been richer, and exciting new developments in radiation technologies are providing new innovative treatments that are more precise and effective than ever before.
Unfortunately, these potentially life-saving therapies come with a very high price tag. For instance, Opdivo, a drug that treats certain types of lung cancer after conventional chemotherapy has failed, costs about $150,000 for the initial treatment, and then $14,000 a month for ongoing therapy.1 The yearly outlay for Keytruda, an immune boosting therapy, totals over $152,000.2 New cancer drugs will be even more expensive in the future, as drug costs are projected to grow 7.5 % to 10.5 % annually through 2020.3 The price could easily reach several hundred thousand dollars for a course of treatment for many of the new drugs currently in clinical trials.
In 2014, the average annual cost of treatment for cancer patients was $58,097.4 As treatment costs rise, hundreds of thousands of patients are delaying care, cutting pills in half or skipping drug treatment entirely. A recent survey found one-quarter of all patients opted to not fill a prescription due to cost.5 Treatment costs can be astronomical for patients without insurance, and even those with insurance struggle to afford high copays, out-of-network care or treatments not covered by their plan.
The financial costs of cancer care are a burden on the healthcare system as well. A 2011 study in the Journal of the National Cancer Institute determined the cost of all cancer care in the U.S. totaled $124.5 billion in 2010,6 the most recent year data was available. National Cancer Institute researchers project the total cost of all cancer care in the U.S. will rise to $157.7 billion by 2020 due to increasing drug costs and a growing elderly population that is more likely to develop cancer.7 These escalating costs are taking a heavy toll on a healthcare system with limited resources.
The Solution: Cost-Effective, High Quality Community-Based Cancer Care
A multitude of clinical studies have verified cancer care delivered in a hospital outpatient department costs significantly more than care delivered in a community setting, without providing any meaningful improvement in quality of care or outcomes.8
The differences between chemotherapy costs in the two settings are striking:
- Private payer costs for chemotherapy in hospital settings were 76% higher than freestanding community cancer clinics9
- The average cost of an office-managed chemotherapy episode was roughly $28,200 while the average cost of a hospital-managed episode was $35,000, more than a 24 % difference10
- Medicare costs by site-of-service were $6,500 higher annually for chemotherapy treatment in outpatient hospital cancer facilities versus independent community cancer clinics11
- Between 2009 and 2012, Medicare beneficiaries paid $4.05 million more in out-of-pocket costs for chemotherapy services in a hospital setting than they would have paid for the same care in a community cancer practice12
A recent study found the cost of radiation therapy in hospitals versus freestanding community-based radiation oncology centers is also higher for the patient. For instance, for prostate cancer patients undergoing IMRT therapy, costs were $3,097 higher in the hospital setting than for the same therapy in a freestanding clinic.13 Three-dimensional conformal radiotherapy for breast patients was $600 higher in the hospital, while treatment for lung cancer with this same technology was $430 higher.14
Community Cancer Care: Better Value―Better Care
Community-based cancer care is a better all-around value for patients, payers and the entire healthcare system, providing many other benefits in addition to cost savings. Conveniently located in local communities where people live and work, patients do not have to travel long distances for access to some of the most advanced technologies, treatments and groundbreaking clinical trials available today. The close proximity to care also reduces ER visits and hospital admissions.
Community centers offer more personalized care than large hospitals, with care provided by one team of professionals who become familiar to the patient. In the hospital setting, patients often see different physicians, nurses and technicians throughout treatment. Community cancer centers also provide convenient access to ancillary support services, such as social workers, financial counselors and other support staff.
At a time when cancer care costs are rapidly rising and becoming unsustainable to the healthcare system, community-based cancer care is the clear choice for patients, providing better value while delivering advanced, comprehensive quality care close to home.
1 https://www.healthnewsreview.org/2015/12/opdivo-ads-vs-the-reality-of-stage-iv-cancer-treatment/
2 http://www.benefitspro.com/2016/05/10/the-role-of-critical-illness-insurance-in-the-new
3 http://www.cbsnews.com/news/the-ever-escalating-cost-of-cancer-drugs/
4 Ibid.
5 https://www.ncbi.nlm.nih.gov/pubmed/23442307
6 www.drugwatch.com/2015/10/07/cost-of-cancer/
7 Ibid.
8 MedPAC to report to Congress, June 2013
9 www.communityoncology.org/pdfs/avalere-cost-of-cancer-care-study.pdf
10 Ibid.
11 http://us.milliman.com/uploadedFiles/insight/health-published/site-of-se…
12 Berkeley Research Group, Impact on Medicare Payments of Shift in Site of Care for Chemotherapy Administration, June 2014
13 Avalere analysis of 2012 5% Medicare Outpatient Claims file. Any visit with a CPT code for radiation oncology was included. Analysis uses payments and packaging policies for 2014 and 2015P, and includes physician payments in both settings
14. Ibid.
By Neelima Denduluri, M.D. | October, 2017
In my career as a medical oncology and breast cancer specialist, I have seen great advancements in the treatment of breast cancer with innovative new drugs and therapy. The outlook for breast cancer patients has never been better, as promising new developments are leading to more effective preventative strategies and late-stage treatments.
Over the last decade, we have seen dramatic advancements in treating many different forms of breast cancer, from early onset to late-stage diagnosis. Progress has been made with estrogen receptor breast cancer using aromatase inhibitors and tamoxifen, or fulvestrant, to regulate the estrogen signaling pathway. This anti-estrogen therapy is the cornerstone of treatment for about two-thirds of women with breast cancer, as their tumors over express estrogen or progesterone. While we have had great success with anti-estrogen treatment for estrogen receptor breast cancer, in some women cancer cells escape the signaling pathway and continue to grow.
CDK4/6 inhibitors are transforming late-stage treatment
Recently there have been some exciting developments in treating patients with an oral oncolytic called abemaciclib, a CDK inhibitor selective for CDK4/6. Rampant cell growth in many cancers is triggered by a loss of cell cycle regulation due to intensified signaling from CDK4/6. Abemaciclib obstructs the growth of cancer cells by specifically blocking cyclin-dependent kinases, CDK4/6.1 This induces cell cycle arrest, especially when combined with endocrine therapy.2 CDK4/6 inhibitors have revolutionized how we treat estrogen receptor positive stage 4 breast cancer, delaying the time to chemotherapy and increasing the amount of time patients can stay on anti-estrogen therapy when these drugs are added to the anti-estrogen regimen.
Since CDK4/6 inhibitors have been so effective in late-stage breast cancer, several clinical trials are now evaluating their use for patients with hormone positive, HER2– negative early breast cancer who are at high risk for reoccurrence. Two of the CDK4/6 trials are currently in progress across the US Oncology Network (The Network) for early stage patients; one investigating a drug called ribociclib and another studying abemaciclib. Both drugs were recently approved for late stage indications. I am hopeful that the benefits translate to high-risk early disease, giving patients a positive outlook early in their breast cancer journey. As a breast cancer specialist, I am very excited to offer these cutting-edge trials within The Network, giving patients convenient access to these novel therapies within their own community.
New options for HER2 positive cancer
Many promising trials are also occurring throughout The Network for early high-risk HER2 positive patients. Most women treated for HER2 positive disease do well with Herceptin along with chemotherapy. However, 10 to 15 percent of women still have a reoccurrence of the disease. We can now treat these women with a drug called pertuzumab. Some sites within The Network participated in an exciting clinical trial investigating the addition of pertuzumab to standard-of-care Herceptin in early, high-risk HER2 positive patients. The APHINITY Trial found that adding pertuzumab as a second HER2-targeted medicine modestly improved outcomes in node-positive women with HER2 disease.
Another drug, neratinib, has recently been approved for maintenance in women with HER2 disease who have been treated with Herceptin and chemotherapy, providing a new treatment option for patients who remain at significant risk after targeted therapy.
Progress for triple-negative patients
Triple negative disease remains an elusive form of breast cancer to treat in some women, as there is no known actionable target as in other breast cancers, but we’re beginning to see progress. Traditional therapy utilizes chemotherapy by itself, which can be very effective in many women. However, we are trying to improve on that approach by testing for genetic mutations. We know, for example, that a greater proportion of triple negative patients harbor germline mutations inherited from their parents, making it even more important for us as physicians to know the familial history of our patients.
To gain this insight, The Network has a comprehensive cancer risk assessment initiative — the Genetic Risk Evaluation and Testing program — that advances precision care by providing individualized genetic data that may lead to cancer prevention opportunities and better treatment options. For instance, if triple negative patients are BRCA1/2 positive, they may be eligible for a class of drugs called PARP inhibitors.
For women with triple negative breast cancer where traditional chemotherapy has failed, immunotherapy looks promising. There is also a new drug, IMMU-132, that is demonstrating positive results in early studies. We encourage eligible patients to participate in clinical trials, as they may experience significant benefits while also playing a pivotal role in advancing cancer care for tomorrow’s patients.
A bright future for many breast cancer patients through targeted care
This is a very exciting time in breast cancer care, as the depth of knowledge we have accumulated is providing a strong foundation for successful treatment. We know that incorporating a healthy lifestyle with traditional anti-estrogen therapy and chemotherapy is very important. In addition, we are perfecting the ability to match the right patients with the right drug(s) at the right time, delivering more personalized, targeted care. For patients with advanced disease, we have many molecularly targeted trials, providing promising new treatments that deliver on the hope of a better tomorrow for all breast cancer patients. I am proud of the work we are doing in The Network to advance cancer care for patients everywhere and look forward to continued progress in providing our patients with the best advanced treatment options available.
1. https://investor.lilly.com/releasedetail.cfm?ReleaseID=1022428
