Paul Celano, MD, FACP
ASCO established a State Affiliate Council in 2012 consisting of representatives from each of the Society’s 48 state or regional oncology societies. The Council met on April 21–22 at ASCO headquarters in Alexandria, Virginia.
The ASCO Post talked with Paul Celano, MD, FACP, President, Maryland/DC Society of Clinical Oncology and Chair of the ASCO State Affiliate Council, about the Council’s work over the past year. Dr. Celano is Director of the Sandra and Malcolm Berman Cancer Institute, Greater Baltimore Medical Center, and Assistant Professor of Oncology, Obstetrics and Gynecology, at Johns Hopkins University School of Medicine.
Clinical Pathways
What have been the State Affiliate Council’s priorities this year?
One priority has been the proliferation of clinical pathways, established mainly by insurance companies to say how therapies should be administered. The issue is that there are so many different insurance companies and clinical pathways, with no common standards for their development.
ASCO and the State Affiliate Council have helped in dealing with state legislation in Connecticut and California, and we expect that additional states will be addressing pathways through legislation. ASCO issued a policy statement that outlines recommendations on the development of clinical pathways to ensure quality and value-based care. The State Affiliate Council identified this issue as a priority and prompted this policy statement through a request to the ASCO Board of Directors.
Has the Council’s work on this helped make a difference?
I think it has. First, the Council raised the red flag on this issue within ASCO. Second, this is a complicated issue that has evolved in a way that allows the private insurance carriers to have considerable influence. What we’re saying is, yes, pathways can be an effective tool, but only if they are developed according to certain criteria.
This is the first time that a dialogue has been opened up, and it’s giving us a voice. But there is still a tremendous amount of work to be done. We need better transparency regarding how these pathways are developed and who is developing them. Also, there need to be uniformity and consistency across these pathways so practices are not dealing with 10 or 15 different sets of rules.
There is also the related issue of preauthorization. Even if we’re following the pathways, we often have to go through an onerous preauthorization process, which consumes a lot of practice time and delays testing and therapies for patients. We don’t think that’s right.
Additional Concerns
What are some other top issues?
Chemotherapy safe handling is also a top issue for the Council. A set of requirements for practices is being set by the U.S. Pharmacopeia—the USP Chapter 800 ruling—which the states can adopt. The State Affiliate Council has been involved in getting input into these rules that specify that chemotherapy has to be given safely, and employees who handle these toxic drugs have to have proper protection.
We all agree with that, but the issue is in the details. Some of the changes they are calling for can affect how we practice, and even whether some practices continue to exist. Georgia, Ohio, Maryland, Virginia, California, Michigan, and Washington have all dealt with efforts to enact this at the state level. Each state has a different variation on the theme, but we want commonsense efforts to allow for proper safe handling so our patients, nurses, and pharmacists are all safe, but they are not so onerous that we’re not able to practice.
The other issue the Council is focusing on is MACRA—the Medicare Access and CHIP Reauthorization Act—which is a new way of paying physicians by Medicare. The sustainable growth rate that Medicare had used was flawed, and Congress changed that by passing MACRA. It’s an interesting law, because it requires physicians to use electronic health records and quality measures and pays according to those metrics.
The State Affiliate Council is made up of the community doctors who take care of the majority of patients in this country, at community practices and community hospitals. It’s ASCO’s window into what is happening on Main Street, in towns and cities around the country.— Paul Celano, MD, FACP
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ASCO has a MACRA Task Force that many of us on the State Affiliate Council have been involved with, dealing with how to prepare ASCO members for MACRA. These discussions include what quality measures CMS [Centers for Medicare & Medicaid Services] should use, what should be measured, and how we should measure them, so that these things are useful and done in a way that doesn’t overburden practices.
Another issue that has taken a huge amount of the Council’s attention is the proposed Medicare Part B drug payment model, which would drastically reduce the amount that oncologists are paid for chemotherapy. Currently, the difference between what we pay for drugs and the amount we receive supports other things in our practices, such as infusion nurses, social support, palliative care support, financial support for patients, counseling, pharmacists, and drug storage.
Under the proposed Medicare project, some of the estimates are that up to 40% of therapies given by oncologists will be “under water,” meaning that Medicare will pay us less than what we paid for the drug. It’s unclear how physicians will be able to practice under these circumstances.
At the recent State Affiliate Council meeting, close to 25 oncologists went to Capitol Hill and held over 50 meetings with their congressional representatives and staff, urging them to prevent this demonstration from moving forward.
On all of these issues, the Council’s involvement is having an impact. There’s a lot of engagement from Council members and a constructive partnership with ASCO. One of the things we’ve learned is that our members on the State Affiliate Council want ASCO to be more proactive in helping us with these advocacy issues, particularly on the state level. ASCO held a focus group in January to hear more about the needs of the state societies and how to become more nimble when members raise time-sensitive issues. There is now a tracking system that lists the status of state issues, state contact information, and ASCO staff assigned to help. That has greatly enhanced our communication.
Timely Developments
What has made this such an important year for state-level advocacy?
There’s just a lot happening. As things get stalled at the federal level, people are looking to the states to pass legislation and make policy changes.
MACRA alone has been huge. This is a bigger change to the practice of medicine than the Affordable Care Act. MACRA has to do with the entire practice of medicine. This is all completely different. Previously, you saw patients one-on-one and you took care of them, and that was it. I think a lot of this is good, but we need the details to plan for the future and know how to budget for our practices.
Council’s Unique Role
If you were to identify what makes the State Affiliate Council unique in helping ASCO, what would you say?
I’d say it’s the two-way communication and collaboration between ASCO, the ASCO Board, and the grassroots. The State Affiliate Council is made up of the community doctors who take care of the majority of patients in this country, at community practices and community hospitals. It’s ASCO’s window into what is happening on Main Street, in towns and cities around the country.
It’s also good for community doctors who don’t have access to a lot of resources. When you’re trying to deal with clinical pathways in your state, and insurance companies are pushing something, you’re just a doctor, you’re a little bit outgunned. You need someone behind you to help with information and support and legitimatize what you’re doing, and that’s what ASCO is providing. And we help ASCO. It’s a mutual situation.
By mutual, you mean that the Council identifies trends that you bring to ASCO?
Right. The clinical pathway trend is a good example. The Council has served as the canary in the coal mine on issues like pathways and USP 800. The activity on those issues was generated through the State Affiliate Council. We have a unique ability to identify trends and issues earlier than they would appear on ASCO’s radar, and we bring them up. Many of these issues were problems in my state of Maryland and, as it turned out, in other states as well.
Road to Involvement
How did you get involved in the State Affiliate Council?
I started as a member of my ASCO state society, and then they asked me to be the liaison to our state medical society, where I realized there were so many different issues out there. I became a member of our state society executive board and then President of the Maryland/DC Society of Clinical Oncology. That got me a membership on the State Affiliate Council.
From there, you could see that the issues we had dealt with locally weren’t just local issues, but variations on problems seen throughout the states. I became Chair of the Council this past year. It has been a great experience to work with the other members of the Council and ASCO staff. I’ve learned a lot and had an opportunity to contribute.
When you’re dealing with complicated issues like health care, there is no end to it. It’s a process. I’ve found it very rewarding because I feel like I’m trying to make a difference. As community doctors, if we don’t make a difference, our patients are going to get lost and will not get good care.
Ongoing Activity
Does being on the Council take a lot of time away from your practice?
It takes time, no question. There are advocacy issues we have here in Maryland involving a fair number of educational meetings, as well as discussions with our state and local representatives. We spend a lot of time talking with our state secretary of health and occupational safety people. I’ve had to testify in front of our state legislature several times. It’s a fair amount of work, but I’ve liked it.
Once you get hooked on ASCO committees, it can be very addictive, from what I understand.
Yes, I’m Chair-Elect of the Clinical Practice Committee, so that’s my next step. I will become Chair in June.
Congratulations. Will you remain active on the State Affiliate Council?
I will not be in a direct leadership role, but I will certainly be active because there are a lot of common and important issues. ■
Disclosure: Dr. Celano reported no potential conflicts of interest.
