Although community oncology practice may have been changing before the COVID-19 pandemic, it amplified industry trends. At the 2022 Community Oncology Alliance’s Community Oncology Conference, a panel of experts discussed issues related to the future of community cancer care, including reimbursement structures, home infusion therapy, telemedicine, and the oncology drug market.
The moderator of the session, Barry Russo, MBA, Chief Executive Officer of the Center for Cancer & Blood Disorders & OneOncology, was joined by Glenn Balasky, Executive Director, Rocky Mountain Cancer Centers; Emily Touloukian, DO, President, Coastal Cancer Center; and Jeffrey Vacirca, MD, FACP, Chief Executive Officer, New York Cancer & Blood Specialists.
Barry Russo, MBA
Glenn Balasky
Emily Touloukian, DO
Jeffrey Vacirca, MD, FACP
Reimbursement, Precertification, and Preauthorization: An Uncertain Future
With the Oncology Care Model set to end by 2022, there is uncertainty regarding the next oncology payment model from the Center for Medicare and Medicaid Innovation (CMMI). “The principles of value-based care are here to stay,” said Mr. Balasky, and there is great opportunity to transform current reimbursement structures. However, stakeholders should expect an “awkward transition” to Oncology Care First, as the CMMI accounts for lingering effects of the pandemic.
Dr. Vacirca, on the other hand, questioned the term ‘value-based care,’ noting that what’s valuable to payers is not necessarily what’s valuable to community oncologists. “Approximately 90% of patients in New York have insurance through a payer, and the payer just serves as a TPA [third-party administrator],” said Dr. Vacirca. “That means they do not have any incentive or intent to drive premiums down. In fact, if they drive premiums down as a TPA, they make less money. Employers have no clue that the payers are working contrary to what’s in their [the employers’] best interest.”
Precertification and preauthorization, the processes of obtaining approval from a health-care payer for services that will be provided or have already been provided, respectively, are additional impediments to quality cancer care, according to Mr. Russo. “These resource-intensive processes have become increasingly difficult to manage and have a negative impact on revenue cycle management, which is the lifeblood of our practice,” said Mr. Russo.
“We have no idea what these delays to patient treatment [caused by precertification and preauthorization] are costing us in patient lives,” Dr. Vacirca added.
Site-of-Service Limitations
Commercial payers have recently instilled site-of-care policies, allowing patients to receive cancer care in non-inpatient settings, such as a home or an ambulatory infusion center. According to Dr. Touloukian, the concept of home infusion may initially sound like a great idea, but there are significant patient safety concerns as well as questionable cost savings.
“Getting IV fluids at home paves the way for more dangerous situations, such as home infusion of biologics or chemotherapeutics,” said Dr. Touloukian. “There’s also genuine value to laying eyes on your patients who are in the clinic for IV fluids. You can address adverse effects from treatment, make changes to their treatment, decrease morbidity, and perhaps avoid hospitalization, which is itself a cost saving.”
In addition, Dr. Touloukian noted that home infusions are a poor use of limited nursing resources. Whereas one nurse in a clinic can treat multiple patients simultaneously and back-to-back, she said, a home infusion encounter involves traveling to and from a location to treat a single patient.
“There are so many intangibles that you can catch with patients when they’re in your office,” Dr. Vacirca added. “I cannot figure out how having a nurse drive to someone’s house and dedicating a few hours to a single patient could possibly be less expensive.”
Telemedicine: A Natural Evolution of the Provider-Patient Relationship
The COVID-19 pandemic incited a dramatic shift toward telemedicine for outpatient health visits. Although this technology is here to stay in one form or another, Dr. Touloukian noted that its utilization will likely evolve over time.
“I was a very early adopter of telemedicine in my patient clinic in the pandemic, but having patients’ labs drawn in the parking lot and doing virtual visits the next day is no longer the way that I’m using it,” she explained. “Nevertheless, I think telemedicine is great for staying in touch with our patients and for disseminating information in a real-time way to family members.”
“It’s remarkable that we didn’t start utilizing this technology sooner,” Dr. Touloukian added.
According to Dr. Vacirca, providers who have been calling patients to discuss results have been practicing a low-fi version of telemedicine for their entire careers—for free. Changes to reimbursement structures are just now supporting fair compensation for their work.
“Finally, there’s an opportunity for us to continue what we’re doing—having that patient connection and seeing them at the same time—and get paid for the work we do,” said Dr. Vacirca. “It’s validating what we’ve been doing for the past 20 years, and it would be a travesty for [telemedicine] to go away. Obviously, it doesn’t replace being hands on with patients, but it is an extension of what we’ve always done.”
Oncology Drug Market
Finally, the rising costs of prescriptions drugs combined with a lack of transparency from pharmacy benefits managers are driving another trend in oncology: the formation of employer coalitions to address health-care benefits and lower health-care costs. The conventional wisdom, said Mr. Russo, is that employers can use combined scale to negotiate lower drug prices with large pharmacy benefits managers.
“The employer market is evolving,” said Mr. Russo. “Employers are not happy with the outcomes they’re getting from the current third-party administrator and pharmacy benefits manager structure, and they’re starting to see real savings by pulling together.”
Dr. Vacirca, who recently instituted a self-insurance plan at the New York Cancer & Blood Specialists, said that removing a pharmacy benefits manager and sourcing drugs directly saved approximately 20% to 30%. “It’s remarkable how much money is wasted with pharmacy benefits managers,” said Dr. Vacirca. “I would encourage everyone to make that effort and find an alternative.”
DISCLOURE: Mr. Russo, Mr. Balasky, Dr. Touloukian, and Dr. Vacirca reported no conflicts of interest.
