Oncology Practice Trends and Pressures

Meg Barbor, MPH

November 2017, Vol 7, No 11 - Practice Management


New Orleans, LA—An American Society of Clinical Oncology (ASCO) Oncology Practice Trends Survey from 2015 to 2016 revealed that increasing practice or facility expenses, drug pricing, and issues with electronic health records (EHRs) were among the top practice pressures cited by oncologists.

At the 2017 Best of ASCO meeting in New Orleans, John Cox, DO, MBA, FACP, FASCO, Professor, Division of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, discussed pressing realities currently on the horizon for oncology providers.

Drug Pricing

“I think every one of us feels our patients’ pain when we talk to them about purchasing prescription drugs, and, clearly, practices are also affected by the high cost of acquiring drugs,” said Dr Cox. “Drug pricing is a big issue, but it’s one issue that many members of Congress have heard us about.” Although bipartisan attention is focused on drug pricing, opinions vary greatly.

ASCO holds physicians accountable for utilization, but not for market entry drug pricing. “One of the principles that ASCO is pressing is that drug pricing is certainly an issue that affects practices and patients, but it’s not an issue that should be borne by physicians and oncologists in and of itself,” said Dr Cox. “We’re responsible for how to utilize expensive drugs, and we should be accountable for the quality of care we deliver, but we should not be accountable as a result of the high price of drugs.”

The Medicare Payment Advisory Commission, an independent congressional committee that advises Congress on Medicare policy, has continually advised Congress to put pressure on decreasing the high cost of drugs through proposals such as competitive pricing and mandatory average sales price data reporting, and has resurrected these proposals many times. But ASCO and others in the community have opposed these recommendations.

“This is one area where community oncology raised up and pressed hard to get these proposals withdrawn, but these proposals aren’t going to go away,” Dr Cox said. “We need strong advocacy and voices talking to members of Congress, making them aware that yes, those drug prices need to be dealt with, but it shouldn’t be on the backs of practice.”

“ASCO has long represented us and advocated for comprehensive payment reform,” he continued. They argue that to remove margins on drugs, payment to cover other expenses of services rendered must be increased. “Only through that kind of comprehensive payment reformation can you consider removing those extra dollars that come from drug margins, because that’s what keeps the lights on in most of our practices.”

Administrative Burdens

According to a study reported in the Annals of Internal Medicine, physicians only spend approximately 27% of their time with patients (Sinsky C, et al. Ann Intern Med. 2016;165:753-760). For every hour spent with patients, 2 additional hours are spent on the EHR and completing desk work, with an additional 1 to 2 hours of personal time each night spent on the EHR.

“I think every day, every one of us experiences the burden of required documentation,” Dr Cox said. “And one wonders if it’s really forwarding the quality of care.”

Advocacy has grown around increasing awareness of this issue, and organizations such as ASCO, the American Medical Association, and the American College of Physicians are pursuing remedies to the increasing administrative burden. A growing consensus argues that Congress, the Administration, and payers need to ease the burden on physicians and allow for more time with patients. They propose that this can be accomplished through the facilitation of appropriate use of clinical pathways, increasing the interoperability of EHRs, lightening up on prior authorization and payer requirements, and streamlining quality reporting.

Legislation attached to the 21st Century Cures Act (which was passed in December 2016) is also aimed at achieving interoperable EHRs by preventing information blocking and harnessing the potential of big data. “Hopefully we’ll come to a better place, with better interoperability of care, in which we can truly see an EHR that helps serve us, our practice, and our patients more transparently,” said Dr Cox.

In addition, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the Quality Payment Program (QPP) are pushing medicine away from a fee-for-service model and toward increased accountability. “This is a movement that is not going to stop, regardless of the current Administration,” he said. Over the next 5 to 10 years, the QPP will force practices to choose 1 of 2 paths: the Merit-Based Incentive Payment System (MIPS), or Alternative Payment Models (APMs).

“Most of us are going to go through MIPS for a while,” Dr Cox said. “And you have to participate in this; you can’t dodge it.” Currently, only the Oncology Care Model qualifies a practice as an APM.

Under MIPS, 2017 is a data-collecting year, and full reporting is not required, but the minimum requirements must still be met to avoid penalties in 2019. “Whether you’re in an institution or an independent practice, this is very important to your practice,” Dr Cox said. “The rules are changing, but the spirit of this program is not going away.”