Practices Look to GPOs Even as Reimbursement Cuts Loom

Bruce Gould, MD

Community oncology practices are at a crossroads despite the maturity of the marketplace. Running an efficient oncology practice is getting tougher and tougher, said Bruce Gould, MD, medical director at Northwest Georgia Oncology Centers in Marietta, Georgia.

“We deal with declining reimbursement— especially from Medicare and Medicaid. Practices just got a 30% haircut off of drug margins last year because of the sequestration cuts. There are continuous cuts, from 1 to 2% in the Medicare evaluation and management codes for physician services and chemotherapy administration codes,” said Gould.

Traditionally, oncology practices subscribed to the buy-and-bill model of drug delivery. Practices purchase the infusion-based or injectable therapies from drug wholesalers or group purchasing organizations (GPOs) that they administer to patients, rather than having these expensive medications dispensed through a retail or specialty pharmacy.

The practices store the medications as inventory onsite, administering directly to patients as needed. Practices then bill Medicare or private insurers, or collect copayments or coinsurance from patients. In the short term, it keeps the practice afloat and a steady stream of revenue flowing in. One study suggests that nearly 80% of an oncology practice’s revenue comes from the buying and billing of drugs.¹

However, the model does open the practice up to a certain amount of financial risk because inventoried medications can expire or too much medication can be purchased without being administered. The practice could end up with a stockroom full of worthless medication. Inadequate reimbursement from both public and private insurers is also a distinct possibility.

Enter GPOs

That’s where group purchasing organizations come in. More than drug distributors, GPOs can help practices “remain financially healthy by providing tools and technologies that optimize financial performance and maximize practice efficiency,” says Jeff Lovesy, vice president of Physician Office Sales for Cardinal Health Specialty Solutions. These tools include practice analytics, reimbursement, inventory management, and financial analysis.

One core benefit of a good GPO is its ability to offer value through pricing, according to Barry Fortner, PhD, president, ION Solutions, an AmerisourceBergen company.

Many factors contribute to a GPO’s ability to secure this value, including size of its membership, longevity in the market, and historical performance.

“The value of a GPO goes far beyond the pharmaceutical contracts offered by including additional services such as educational opportunities, nondrug vendor partnerships that offer value, convenient access for services and technologies, and the creation of a unified community of practitioners,” continued Fortner.

In addition, GPOs can help practices remain independent by providing “better pricing on drug purchasing and information about drug rebates. This leads to lower cost of goods and improved operating margins for the practice,” says Gould.

The expertise provided by the GPO can improve practice efficiencies so that “the practice can have more money to keep within the practice to help with the bottom line,” he adds. Gould points out that GPOs, while often obtaining better prices on oncology agents, can be the only source to purchase certain medications.

He readily admits that 5 or 6 years ago, like most oncology practices, “We focused on our IV business. As long as it was making a few bucks and paying for itself, we were satisfied.”

Growing Involvement

GPOs have grown in importance to community oncology practices, with two-thirds of practices having a relationship with both a primary and secondary GPO, according to an August 2013 survey² by Kantar Health, an evidence-based decision support partner to pharmaceutical, biotechnology, device, and diagnostic companies (see Figure 1: Community Oncology Practice Distributor/GPO Affiliation).

Meadow Green, a consultant in the Commercial Strategies Group of Kantar Health, says that according to the survey, “The number 1 reason for choosing a GPO is contract pricing and purchasing programs. That’s what is driving practices to develop relationships with these entities” (see Figure 2: Important Services Provided by GPOs).

“In the current reimbursement environment,” claims Fortner, “being involved with a GPO is essential.” He says that “It is difficult to imagine a practice not being a member of a GPO.”

The advantages are:

• Reducing costs and increasing cash flow
• Improving product access and reimbursement
• Driving practice efficiency and enhancing patient care
• Increasing physician education and engagement

The relationship between GPOs and practices isn’t just a one-way relationship, however. With more oncology practices merging with local hospitals and medical centers, which often have their own GPOs, the part of the market consisting of independent practices is shrinking and that is affecting GPO business as well.

Oral Oncolytics

Oncologists and hematologists in the buy-and-bill model are reimbursed for the office visit, the infusion service, and the intravenous drug itself.

“As more oral oncolytics become available—and assuming similar efficacy—oncologists will only be reimbursed for the office visit. The oral oncolytic gets adjudicated through the patient’s pharmacy benefit and the potential for payment will be lost to the oncologist,” says Lovesy.

Practices are adapting to the growing prevalence of oral oncolytics in a number of ways. These include starting, or expanding, their in-house dispensing pharmacy, partnering with retail pharmacies, and sending prescriptions to specialty pharmacies for dispensing.

“Oral oncolytics represent a real opportunity for practices, especially to offset areas in which we’re under-reimbursed,” said Gould. Lovesy added that “GPOs must position themselves to support the oral dispensing strategy that best fits the oncologist’s practice model, regional payer requirements, and patient mix.” Growing its in-house pharmacy dispensing service was Northwest Georgia Oncology Centers’ objective when it approached RainTree Oncology Services.

Figure 1. Community Oncology Practice Distribution/GPO Affiliation

Gould says the company focused the practice’s attention on the pharmacy, where it hadn’t been before. Along with providing expertise on how to run a better pharmacy and how to provide better care for patients, the practice was able to “increase our capture rate so that oral prescriptions weren’t walking out the door and down the street.”

RainTree also staffed Gould’s practice with relationship managers, essentially pharmacists who had run other pharmacies in other practices. “They provide the expertise and focus on pharmacy operations to improve efficiencies and provide better patient care,” says Gould.

In the current legislative and regulatory environment, the pressures on oncology practices are mounting. GPOs are one way to keep practices viable.

“Some practices are drowning in administrative burden,” says Green. “A practice has to identify what its needs are. Practices can have primary and secondary affiliations to comparison shop on prices—drug prices or information technology. But the practice solutions that GPOs offer are robust and useful,” she continued.

The buy-and-bill model hasn’t completely gone the way of the dinosaur, yet.

“Oncology payment reform is evolving, and it’s early in its evolution. Many would like oncologists to move away from relying on drug margins to keep their practices afloat, replacing current reimbursement models with pay-for-performance type models. But I don’t see the buy-and-bill model going away and I don’t see the GPO model going away anytime soon,” said Gould.

Figure 2. Important Services Provided by GPOs

Percentage of Practice Managers Ranking Each Service (n = 56)

Source: Kantar Health; Practice Manager Survey 2013—Q9.4 Which of the following services/attributes are most important to you in your current group purchasing organization(s) (GPO)? Please rank the top factor as 1 = most important, the next as 2 and the third as 3, etc.

References

1. Akscin J, Barr TR, Towle EL. Key practice indicators in officebased oncology practices: 2007 report on 2006 data. J Oncol Pract. 2007;3(4):200-203.
2. Kantar Health. Channel dynamics. Oncology Market Access US. August 2013