Lack of Drug Information Makes it Hard to Get Payer Approvals

Andrew L. Pecora, MD

Data collection has to be improved in order for physicians to be able to convince payers to support certain types of costly therapy, a panel of physicians agreed during a wide-ranging OncLive Peer Exchange conducted at the 2015 ASCO Annual Meeting.

Payment issues, electronic health reporting, how to attract younger physicians to oncology, and the growing role of women physicians in this traditionally male-dominated profession were discussed in the Chicago forum.

Below is an edited and condensed version of the discussion, which was moderated by Andrew L. Pecora, MD, editor-in-chief of Oncology Business Management and chief innovations officer at John Theurer Cancer Center in Hackensack, NJ. Participants included Michael Kolodziej, MD, national medical director of Oncology Solutions, Aetna; and Jeffery C. Ward, MD, of Puget Sound Cancer Centers, Edmonds, Washington.

A range of oncology practice management issues were discussed in an OncLive Peer Exchange meeting held at the 2015 ASCO Annual Meeting in Chicago. Participating were Jeffrey C. Ward, MD; Andrew L. Pecora, MD; and Michael Kolodzeij, MD.

Andrew Pecora: Suppose in the advanced stages of treatment you get a positive signal that says an mTOR inhibitor might work with a patient. Of course, it’s not FDA-approved, and the payer won’t pay for it, and the patient can’t afford to pay for it. What do you do?

Michael Kolodziej: I think the big challenge for payers is trying to sort out what’s legitimate and what’s not. The question is, how do we get payers to say “Yes”? If we could develop a methodology by which we actually collected information about these one-offs, we would not only improve care for all patients with cancer, but we would make the no-yes dichotomy a heck of a lot easier for payers.

Jeffery Ward: I think that you explain that this is a very rare case, and you’ve done this test and it demonstrates that it may work. And insurers say, “Yes, we will pay for it as long as that data gets into a registry—that we learn from it.” You know that 97 percent of the care that we give, we learn nothing as far as outcomes.

Michael Kolodzeij, MD

AP: How do you view the rapid movement toward personalized medicine— the use of genomic testing, and the new and expensive medications such as checkpoint inhibitors?

MK: Now, we’re restricting care really to patients who have either a high risk of systemic disease or have systemic disease, and they are clearly the single most expensive group of patients. The general thinking is that we would like to make sure that the right patient gets the right treatment at the right time. What I think is not necessarily a path forward is unbridled enthusiasm and, “If it works in this, it must work in that.” I’ve heard it more than once: “I’m an oncologic chef.” Those days are over. You had better be a good oncologic short-order cook, because we depend on you to make that hamburger right. But an oncologic chef where you decide you’re going to try a little bit of ingredient A and ingredient B is probably an unsustainable approach going forward.

AP: What about disparities in cancer care?

JW: I think disparities are predominantly created by access. The barriers to access can include socioeconomic barriers, and language barriers when we’re talking about immigrant populations, and then cultural issues. There are some issues with trust with the medical establishment. I think if you remove those barriers and patients have access, you’re going to see most of those disparities go away.

AP: How should we think about and address the comorbidities and behaviors that lead to cancer?

MK: This probably is the primary intent of the quality metrics which have been widely criticized—for example, Administration for Community Living (ACL) program in Medicare. The idea that we can improve population health with the ACL—making sure that people get their mammograms, have colonoscopy, have their A1Cs checked, don’t use cigarettes, and monitor their weight—is population health management. This is not really an oncologist issue. This is an issue for primary care.

AP: How do we encourage more young physicians to enter the oncology field?

JW: Well in our payment reform session here at ASCO, one of the commentors was a young oncologist, and he stood up and said that people are not going into oncology because of the uncertainty and the reimbursement system, and in their perception, oncology is a place where doctors struggle to be happy.

I think that the way to change that is to deal with a payment reform piece— deal with that in a big way. Once you get it out of the way, then oncology is going to be a glamor profession.

MK: I’m not sure I’d call it a glamor profession, but make it a really fulfilling career decision, and make sure that it involves team-based care. I’m a big fan of the Medical Home Model, and one of the core principles of the Medical Home Model is team-based care. And I aspired to that when I was in practice, but there was no scaffolding upon which to execute that. Team-based care diffuses some of the responsibility but also enriches the career paths of all those people who are part of the team, and I think that’s really key.

AP: There’s a rising population of women who are now practicing oncology. How is this significant and relevant for the field?

JW: If you look at new medical school classes, many of them are more than 50 percent female, and I think that that enriches and brings a reality to what we do and is changing some of the paternalism of how we practice in a very positive way. It does create some struggles. I think that’s evident not just in medicine but across the United States where we’ve changed from a culture where you have a single breadwinner to 2 breadwinners. What does that do to your family life and to relationships?

AP: Let’s talk about traditional models of care and payment, fee-forservice, chemotherapy “buy and bill,” and your thoughts about new models.

MK: The system is problematic insofar as it creates the impression of conflicted interest. But because of this perception of perverse incentive, there has been a continued erosion of the way chemotherapy gets reimbursed. The buy-and-bill model, which has funded the infrastructure to allow community practices to perform, I think, is in jeopardy.

AP: How do we move from being paid for services to being paid for a product?

MK: You have to somehow indirectly reward the physician for, if you will, good behavior. I think it gets to be really complicated.

JW: I have real problems with bundles. I think that you have to be very careful about how they’re constructed and what you’re doing. I think that bundles will prove to be, if we do them wrong, a way that will further consolidation and further the [mergers] into institutions, whether that’s good or bad. AP: I think we all agree that the site of service does impact cost, and that the best place for a cancer patient to get their care is in the community setting, in a private office, in most cases. How do we preserve that model?

Jeffery C. Ward, MD

MK: I think the truth is that a lot of community oncology practices have focused a lot of their business efforts, operational efforts, on the efficient administration of chemotherapy. That’s what they do, and they do it well. What I’m proposing is that we rethink and potentially retool to deliver the optimal patient care experience.

Whoever, whatever the nurse is who’s doing the calls—you know what’s going to happen, right? Whoever the Incident 2 physician is that day, you know what’s going to happen. So all I’m saying is, we need to get practices comfortable with the idea of examining processes of care. And I’m not sure that’s going to cost a ton of money, but it does require a lot of effort on retooling.

AP: How are health exchanges and the new private plans impacting oncology practices?

JW: I think we have to understand that these initiatives are not healthcare reform, they are insurance reform, and much of what’s happening is that there are patients who now have access to the system who didn’t have very good access before. Many of them are still underinsured.

They had a choice when they decided to develop what was an acceptable insurance plan: they could make it cheap or they could make it good, and they made it cheap.

AP: How much time are oncologists spending on documentation?

JW: In our practice we have used two different electronic records in an effort to try and improve documentation and to make sure we’re doing all the right things and increase efficiency. The first one was with US Oncology. It was a medical record that was designed, really, thinking of the physician’s workflow. It did not improve our efficiency but neither did it make our efficiency a whole lot worse. And it served a purpose in that it was searchable if the doctor chose to use it the right way. And I think it improved the care that we gave in many circumstances, if for no other reason than that you could now read what the doctor had decided he wanted to do.

Then we moved to the current system that our hospital uses, and my documentation time increased by about 2 hours every night for the first 6 months. I see probably 2 or 3 fewer patients every day than I saw before, and I spend at least an hour to 2 hours longer documenting what I did.

AP: Are electronic health records contributing to efficiency or are they an impediment to efficiency?

JW: I think there’s huge variability in the way physicians use EHRs, and it’s driven largely by the fact that they are clunky, they require extra work to use right, and so people find workarounds. In our EHR there is a place to do staging. You have to go to that, you have to work through the staging, you have to check boxes. So what do half the doctors do? They dictate the stage in their note and it never goes in the box and it’s not retrievable. So I don’t think that EHRs are doing, in that sense, what they necessarily were promised to do, and it’s because the entry of information is so difficult.