Reforms May Bring Radical Change

OncLive Chairman,

Mike Hennessy

Competitive pressures and profound marketplace changes are a fact of life for the oncology business, and for a practice in San Antonio, Texas, that handles a large population of rural poor, planning sessions routinely involve discussions on how to stay independent and continue doing things the way physicians there feel is best. The START Center for Cancer Care is featured in Oncology Business Management in the first of a series of practice profiles that will look at community oncology around the country and how physicians are adapting to change.

Doctors at START believe that their independence brings them closer to patients by affording them flexible options in care, but they also know that as oncology increasingly becomes more sophisticated and costly, the old way of doing things cannot endure. Gladys Rodriguez, MD, a hematology/oncology doctor at START, has been practicing for two decades and says the romance of being a community practitioner is still there, though a large, well-equipped team is now almost essential.

“The solo practitioners are fading away, not because people don’t like to be by themselves,” Rodriguez told Oncology Business Management. “It’s just that because of the cost of medications, the infrastructure you have to provide, the chemotherapy in your office, because of all the reporting you have to do, it’s almost impossible to meet all of those requirements and still be able to provide the care. And because of that, the number of people who will be able to go to a rural place and try to practice by themselves is very limited.”

This month’s issue covers much ground on the legislative front, where we look at the repeal of the Sustainable Growth Rate formula and what changes the Medicare Access and CHIP Reauthorization Act will bring to the oncology profession at the practice management level. Kavita Patel, a health policy scholar and a managing director of Clinical Transformation at the Brookings Institution, advises in our story on this topic that physicians become more familiar with this legislation and communicate their concerns to the Centers for Medicare & Medicaid Services (CMS), as this legislative reform may be more difficult to influence later.

Doctors will want to pay close attention to the system of performance incentives, which can include steep payment cuts in later years for failure to achieve targets. Patel notes that physicians will not be blindsided by payment reductions, but adds that these are legislative mandates. “The timeline for this is pretty aggressive,” Patel states. “By the fall of this year CMS has to deliver on some of these programs, so the time for feedback is right now.”

This 340B Drug Pricing Program also comes under the lens as we review testimony from a March congressional hearing on efforts to audit this drug discounting plan that began two decades ago under the best of intentions. Department of Health and Human Services Assistant Inspector General Ann Maxwell was frank in her testimony before the House Subcommittee on Health, stating that “diversion” may be an appropriate word for what’s happening to the discount savings available through the program.

In an interview with Oncology Business Management, Gina Villani, MD, MPH, a hematologist/oncologist in the Harlem section of New York City, wonders at the logic that keeps 340B out of reach of her clinic, the Ralph Lauren Center for Cancer Care and Prevention, which has few commercially insured patients. “The whole purpose of 340B was to give a helping hand to people who are taking care of uninsured and Medicaid patients. We’re the perfect candidate, but because of the way they structured it we don’t qualify,” says Villani, who is CEO of the clinic.

Last but not least, our cover story looks at the practice of upcoding—where physicians choose higher paying Medicare codes allegedly to get more money for no extra care. We hear the other side of the argument, that electronic health reporting has finally made it possible for physicians to bill accurately according to the extent of the care they deliver, and also that this trend represents a sort of a catch-up for payments that physicians have been disallowed in the past by various unfair payment policies. It’s an argument that may stand the test of scrutiny, but more scrutiny by CMS and private payers is inevitable.