Threats to Community Oncology Practices
Community oncology delivers greater access, higher quality, and lower costs to patients than other sites of care, but new hurdles, such as healthcare reform, changes to reimbursement, and consolidation, could pose a threat to the quality of care delivered, suggested community oncologists at the 2016 Community Oncology Alliance (COA) annual meeting.
Community Oncology and Payment Systems
Historically, cancer care has occurred in the hospital setting, but as new treatments have been developed, it has migrated to the outpatient community setting. “Over the past few decades, we’ve seen community cancer centers springing up all over the country,” said David Eagle, MD, of Lake Norman Oncology, Mooresville, NC. “And that has really been driven by community oncologists.”
According to Dr Eagle, many advocacy societies rightly focus on supporting research and development of new therapies—toward cure—but attention should also be paid to how care is delivered.
“The payment systems really define whether you support a system or don’t support a system,” he said. And patients pay different amounts depending on whether they are treated in a private physician office or at a hospital-based clinic, because of completely different reimbursement systems.
Patient copays for cancer care are often too high to allow for optimal care; according to Dr Eagle, “this is a major problem, a major burden, and very fundamentally gets in the way of getting proper care.” Part of the reason for this barrier, he said, is that the copayment system that works for primary care completely breaks down in the realm of oncology.
“A lot of times, for us there’s only 1 treatment choice that makes sense, and you either get that treatment or you don’t,” Dr Eagle said. “And I can assure you that our legislature doesn’t understand that fact at all.”
Immediacy Is Vital
According to Dr Eagle, immediacy is vital, particularly for advocates of cancer care.
“If someone is diagnosed with cancer, whatever the flaws are at that time, whatever the holes in that system, that is the care that patients will receive,” Dr Eagle said. “They can’t wait for policy changes to occur.…There’s always a certain immediacy to cancer care that people have to recognize.”
Two of the concerns he hears most often from patients are (1) that cancer care is too expensive, and (2) that cancer care delivery is too complex. Patients complain that they have to build their lives around their cancer care, and not the other way around. The Centers for Medicare & Medicaid Services (CMS)’s Oncology Medical Home is a model designed to address that issue and to build the care delivery system around the patient, Dr Eagle said.
He stressed the importance of keeping delivery systems intact, noting that the voice of the cancer survivor is the strongest voice there is in protecting cancer delivery systems.
The Medicare Experiment
Dr Eagle predicted that the rule proposed by CMS to test a new model for Medicare Part B payments “will throw a monkey wrench in our appropriate care for cancer patients.”
“The CMS experiment leaves a bad taste in everyone’s mouths,” agreed Jeffrey L. Vacirca, MD, Chief Executive Officer, North Shore Hematology Oncology Associates Cancer Center, East Setauket, NY, and COA Vice President. “They think doctors are making millions prescribing these drugs, but there’s a rationale behind it.”
“Even though these drugs are expensive, they’re expensive because they work, and when we use them, people live longer,” he said. “There’s a cost for innovation, and in the US, we often pay that price for the rest of the world.”
According to Dr Vacirca, there is absolutely no evidence that oncologists prescribe cancer treatments based on anything but the individual needs of their patients, and the CMS proposal will only make patients fearful of treatment and diminish their trust in the patient–doctor relationship.
Site-of-Care Shifts and Pathways
“Major site-of-care shifts have been going on for years, and the delivery system is under intense pressure,” said Dr Eagle. Reasons for these shifts include the Medicare Modernization Act, reduced reimbursement, higher payments to hospitals for identical services provided by community cancer centers, and sequester cuts. “Payment and policy conversations can be difficult and boring, but have huge ramifications for patients,” Dr Eagle added.
“I think patients should get to decide where they want to go,” he said. “Right now, the hospital-based system is so intensely advantaged over the private office setting, I think it’s going to leave patients with fewer and fewer choices.”
Hospitals are structurally more expensive and have a growing interest in basing more patient care around pathways, often telling physicians to treat a patient according to what is cheapest and not necessarily according to what is best for the patient, Dr Eagle said. “I can promise you that’s a real dynamic that’s going on, and I think it’s something we need to be mindful of,” he said. “It’s a sensitive conversation, but I think physician oversight is important.”