Jeffrey Vacira, MD
Looking back on 2015 in the field of oncology practice, a lot of the groundwork was laid for what the Association of Community Cancer Centers (ACCC) predicted in a fall report: “increased reliance on team-based care and care provided by nonphysicians.”
Economic and regulatory pressures are not allowing much wiggle room for small, independent practices to survive without affiliating themselves with larger groups of practices or merging with hospital systems; and whether physicians are comfortable with the notion or not, the involvement of multiple layers of non-MD personnel in practice decision making and administration is becoming a larger reality every day.
“The US health care industry, including oncology, is undergoing unprecedented consolidation and integration,” the ACCC wrote in the summary to a fall white paper on industry changes.1
“Hospital systems are merging, hospitals are purchasing provider practices, provider practices are joining to create ‘super-sized’ groups, insurance companies are purchasing hospital systems, and the insurance industry itself is undergoing what some are calling ‘merger madness,’ potentially leaving just three companies controlling half of the commercially insured population in the United States.”
The Demise of SGR
The year 2015 saw the demise of the Sustainable Growth Rate Formula, the unwieldy means of keeping medical payments in line with the growth of national spending. Its replacement, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), brought with it a new set of payment anxieties for physicians in the form of punishment and reward: the Merit-Based Incentive Payment System and Alternative Payment Models (APMs). The first incorporates stiffer reporting requirements and measures of performance, whereas the second involves a movement toward integrated payment models and coordinated care.
MACRA, through its system of financial penalties and bonuses, and through the transparency it imposes on oncology care, clearly possesses the power to incentivize change. Whereas some physicians are concerned about whether practices will be judged fairly, Jeffrey Vacirca, MD, vice president of the Community Oncology Alliance (COA), expresses optimism and says he views MACRA as a means by which the quality and value of community oncology will become more apparent. “Payment reforms that increase quality and decrease cost are a reality right now for us,” Vacirca said. “For those of us in community oncology, we welcome this. We think that any sort of a microscope that looks at quality and value is going to make us look better.”
The Oncology Care Model
The year 2015 also brought an effort by the Centers for Medicare & Medicaid Services (CMS) to launch the Oncology Care Model (OCM), an episodic care payment model designed to spur innovation and value-driven care. Hundreds of practices met the June deadline for applying to be among the first chosen to try this model, but skeptics of that response described the OCM pilot as a choice with no alternatives.
Whereas a poorly fitting suit of clothes can pull and bind, both ASCO and COA are lobbying to cut and tailor their own APMs rather than be forced to pick them off the CMS rack.
Reining in 340B
Efforts to rein in the ballooning 340B Drug Pricing Program (340B) and create some breathing room for hardpressed community practices included the late summer release by COA of a Berkeley Research Group (BRG) report on 340B spending growth.2
Among the statistics was information on how rapidly hospitals are expanding their chemotherapy infusion services, which allow higher reimbursement for drugs purchased at the discounted 340B price.
“Our most recent analysis indicates that hospital outpatient departments accounted for almost 35 percent of all chemotherapy claims in 2013, up from 21 percent in 2010,” BRG said in the September report.
In addition, in just the last five years, the number of 340B covered entities contracting with retail pharmacies and mail-order/specialty pharmacies has soared from just under 1000 to just over 3000, the report indicated. These pharmacy arrangements, which fit loosely into the scope of 340B privilege, are held responsible for the extension of discount benefits into patient populations where relatively little need for 340B is said to exist.