Docs Hesitant to Embrace Genomic Tests

Camilla Zimmermann, MD

A physician’s confidence level in his genomic knowledge plays a significant role in attitudes towards genomic tests, especially in tests that look for changes in DNA that are taken from patients’ tumor samples, according to research from the Dana-Farber/Brigham and Women’s Cancer Center (DF/BWCC).

Physicians who are confident in their ability to interpret and explain the findings to patients were more likely to want to prescribe the test and consider using test results when making treatment recommendations while physicians with lower levels of genomic confidence were less likely to offer the testing, according to the research. Stacy W. Gray, MD, AM, who is the first author of the report, said 42% of responding oncologists approved of telling patients about test results even when their significance for the patient’s outlook and treatment is uncertain.

“The fact that we found so much variation in physicians’ confidence about their ability to use genetic data at a tertiary care National Cancer Institute-designated comprehensive cancer center makes us pause and wonder about how confident physicians in the community are about dealing with this,” said Gray, a thoracic cancer physician at Dana-Farber. “It begs the question at a national level, how are we going to make sure that this technology for cancer care is adequately delivered?”

The researchers report that 160 medical oncologists, surgeons and radiation oncologists participated in a study that asked participants about their current use of somatic testing (ie, testing patients’ tumors for known mutations one at a time), their attitudes about multiplex testing, and their confidence in their ability to understand and use genomic data. The survey did not include a direct test of the physicians’ knowledge. Results of the survey showed that 22% of doctors reported having ‘low confidence’ in their knowledge about genomics. When queried about their knowledge and their ability to make recommendations based on the test results, 14% said they lacked knowledge about how to explain the concepts to patients, and 26% doubted their ability to make treatment recommendations.

Physicians who participated in the survey said they ordered tumor genomic testing for an average of 24% of patients and only 18% of the participants planned to use multiplex tumor testing “infrequently.”

The authors of the study concluded that there is “little consensus” on how physicians plan to use genomics testing for personalized cancer care, and suggest the need for evidence-based guidelines to help doctors determine when testing is indicated.

The study is published in The Journal of Clinical Oncology.

Despite a Low-Tier Ranking, Patients Remain Loyal to Their Personal Doc

Patients were no more likely to switch away from lower-tiered physicians than higher-tiered physicians within their health plan, especially if the physician was considered the patient’s personal doctor, according to findings of “The Impact of Tiered Physician Networks on Patient Choices,” published in Health Services Research.

In a tiered physician network, insurers sort providers into tiers based on cost and quality performance. Patients have a financial incentive— they pay lower cost-sharing—to see a provider in a higher performing tier. The insurer uses this approach in the hope that tiered networks spur quality improvement and cost control by motivating physicians to attain a higher tier ranking. But Anna D. Sinaiko, PhD, and Meredith B. Rosenthal, PhD, found that patients who already had a relationship with a physician continued seeing the physician, even if the physician was in a low-ranking tier. The tier ranking could not overcome the loyalty a patient felt towards his personal doctor.

“Choosing a provider or a health plan is complicated for patients, and there are many factors and sources of information that patients can take into account when making these decisions,” said Sinaiko. “Tiered networks can be an element of this process, so providers will want to be aware of the potential for tier-rankings to impact their patients’ choices both on their own and as part of referrals.”

Sinaiko, a research scientist in the department of Health Policy and Management at the Harvard University School of Public Health, reviewed administrative claims and enrollment data on 171,581 nonelderly beneficiaries enrolled in the Massachusetts Group Insurance Commission health plans that include a tiered physician network. The researchers were trying to determine the effect of a tiered physician network on patient health plan choice.

Using tiers is not a new phenomenon; it’s commonly used for formularies and prescription drugs. There is strong evidence that consumers respond to the cost-sharing associated with tiers by switching to drugs in preferred tiers as designated by the plan. But prescription drugs are very different than physician visits, and drugs are generally viewed as interchangeable.

The researchers report that tiered networks have an effect on physician market share through “channeling of new patient visits away from the lowest tiered physicians.” This finding is consistent with economic theory and common sense: unknown physicians are more likely to be viewed as “substitutable” by patients than physicians with whom patients have a relationship.

“While patients in our study sample exhibited considerable loyalty to their physicians, the use of tiers affected the choices of patients who were selecting new physicians,” said Sinaiko. “These results are economically important for physicians, as these results correspond to a loss in market share of new patients for a doctor in the bottom tier of 12% compared to physicians with better tier-rankings.”

The authors note that the findings might not be generalizable to other populations, such as Medicare or Medicaid, or to tiered networks that impose larger copayment differences across physicians.

Providing Earlier Palliative Care Improves Quality of Life, Patient Satisfaction

Traditionally, palliative care for patients with cancer is geared towards end-of-life measures, but a new study from the Princess Margaret Cancer Center in Toronto suggests patients who receive palliative care earlier in their cancer therapy report improved quality of life and greater satisfaction.

The findings demonstrate the benefits of cancer centers that provide early specialized palliative care in outpatient clinics, says principal investigator Camilla Zimmermann, MD, head of the Palliative Care Program at the University Health Network, and medical director of the Al Hertz Centre for Supportive and Palliative Care at the cancer center.

“Oncologists should be referring the patient earlier to outpatient palliative care teams to provide collaborative care because typically palliative care is provided much later in the disease process,” says Zimmermann who is also associate professor and holds the Rose Family Chair in Supportive Care in the University of Toronto faculty of medicine. “However, a lot of cancer centers and hospitals don’t provide outpatient palliative care teams, so the palliative care team has to make themselves relevant in the outpatient setting. Where it is available, oncologists still tend to refer quite late because of biases and stigmas associated with palliative care.”

The study involved assessing patients with advanced lung, gastrointestinal, genitourinary, breast, and gynecologic cancers whose prognosis was greater than six months. Quality of life, symptom control, satisfaction with care, and difficulty with medical interactions were measured.

All participants completed a baseline survey while receiving the same clinical care over four months. However, the early intervention group received formal monthly consultation with the palliative care team in a specialized outpatient clinic. These 228 patients also received regular telephone follow-up. When the study ended, patients were offered continued follow-up in the outpatient palliative care clinics.

Although the intervention group reported a worse status at baseline, the study showed a trend for improvement in quality of life at three months and clinically meaningful improvement at four months. Patients had undergone cluster randomization, meaning the whole clinic would receive palliative care or not said Zimmermann. “This was a practical issue because it would be more palatable to patients and oncologists to participate,” she said. “The downside is selection bias,” she added.

Similarly, patient satisfaction with care improved substantially at both three and four months in the early palliative care group, while it deteriorated in the control group.

“In the community setting, oncologists and hematologists should attend to the type of issues that palliative care teams can address like symptom control, attention to emotional and spiritual needs, and family needs to help patients and families cope,” said Zimmermann.

Highmark Lowers Hospital-Infusion Chemotherapy Rates

Hospitals and medical centers that provide chemotherapy infusion services to their cancer patients on an outpatient basis generally get paid more than oncologists and hematologists who provide the same services in a private office.

This discrepancy has led one private insurer in western Pennsylvania to re-negotiate the drug acquisition prices it pays to hospitals that provide ambulatory chemotherapy infusion services. Donald R. Fischer, MD, senior vice president of health affairs and chief medical officer at Highmark Health Plan said, “We are no longer going to pay the differential price for the drug itself based on the drug delivery setting.” He emphasized that there would be no change in what Highmark would pay for administrative, professional, or procedure fees. “The price of the drug will be standardized across our network.”

In a news release, Highmark announced that it will use “more rational payments for cancer by eliminating markups to the cost of certain oncology-related services, including infusion chemotherapy drugs.” The new payment rates will go into effect on April 1.

The Centers for Medicare & Medicaid Services (CMS) traditionally provides higher reimbursement rates to hospitals than to physicians in private practice. Private insurers tend to follow CMS’s lead, so Highmark’s move is an interesting development. What effect one insurer might have on runaway cancer costs remains to be seen, however.

“All we are tackling here is the price of the drug. And that’s still highly significant,” said Fischer. William Winkenwerder Jr, MD, president and CEO of Highmark Health said, “We estimate that this billing change will save our community more than an estimated $200 million annually, with no impact to the quality of cancer care.”

The move comes in response to strong objections raised by its members, public officials, and the community at-large to the costly billing practices for oncology services that have significantly increased the cost of health care.

“We’ve received an incredible amount of support from the community saying, ‘It’s about time,’” said Fischer.

An Enhanced HIE Manages Costs and Improves Care

Creating an enhanced, common health information exchange (HIE) pipeline where clinicians, payers, and patients share structured information from multiple electronic medical record/electronic record platforms would effectively manage costs and enhance patient care in oncology, according to a recent paper published in The Journal of Oncology Practice.

“Oncology needs a robust information transfer pipeline. Without information exchange and transparency, it will be difficult moving to a more value-based and outcomes-based system,” said Ira Klein, MD, MBA, senior medical director, national accounts clinical sales and strategy for Aetna.

Klein and Michael Kolodziej, MD, also from Aetna, propose to first integrate existing office electronic health records (EHRs) with the pathway/ guideline support tools that are currently available (eg, eviti or P4 Healthcare Oncology).

The second step involves payers facilitating Webbased pathway or guideline tools that are available and adaptable by practices and enriching those tools with other patient-specific information (eg, laboratory, pharmacy, and pathology) for lowor no-cost use by oncology practices. They note that practices would benefit by receiving realtime structured clinical data and, by interacting with a payer on the other end of the HIE, receive instant resolution of any precertification processes. The final step involves gaining multipayer buyin to standards of care and promoting the idea of having multiple payers have contracts with an oncology practice.

This would allow for “different payers to plug into the system to create incentives and value- driven deals with oncologists, without oncologists feeling like they have to follow multiple different sets of practice requirements on one hand, and on the other, not feel like they are on the receiving end of some sort of collusive relationship with other competitive payers,” said Klein. A large, integrated system could be viewed as a buffet-style menu for community oncology practices, which allows “practices to pull out the data they need to help them develop pay-for-value programs with multiple payers.”

They argue that current pilot programs that use pathways and bundles-of-care programs are interesting, but they are not relevant to a community oncology business model. This is because only a small slice of business comes from the payers who deploy these pilot programs. Practices can’t devote a full-time employee to pilot program implementation and maintenance unless the program can be applied to the practice as a whole.

The proposed information exchange could “improve the workflow of the community oncology practice, pay practices for being smart, for keeping patients out of the hospital, and for demonstrating consistent use of evidence-based medicine,” said Klein. “If you’re in a competitive marketplace and you’re not in a single-payer system, you’re going to have barriers to sharing information. We’re proposing a methodology for allowing data to be shared, and yet continue the same market dynamics that are in existence today.”

The authors write that the unintended consequences of the Medicare Modernization Act and continuing focus on the 340B drug price program (a federal program created in 1992 that requires drug manufacturers to provide outpatient drugs to hospitals at significantly reduced prices) has dramatically shrunk community-delivered oncology care and allowed hospital-delivered care for oncology to grow. “We don’t think that’s a good idea. We don’t have any evidence that this delivers better patient care, better access, promote more personal service, or promote efficient use of services,” said Klein.

“We need to have a value-based pathway for moving community oncologists back to the forefront of care, and do it in a way without crashing the economic model,” said Klein. He recommends that oncologists join with private payers in these experiments and try to broaden and make them the standard of practice across the country. “If they do that, then community oncologists can help to shape the vision of CMS to create changes in pay for value that will be non-noxious to oncologists and non-noxious to patients.”