COA: An Advocacy Group Born in Crisis Looks Back at 20 Years

The Medicare Modernization Act (MMA) of 2003 might be best known for creating the prescription drug benefit known as Part D. But for community oncologists, the law felt like a wrecking ball—it drastically altered how practices were reimbursed when prescribing chemotherapy, in ways that threatened the financial health of some.

In this moment of crisis, a group of oncologists came together and formed the Community Oncology Alliance (COA), which marks its 20th year at this week’s annual Community Oncology Conference, taking place in Kissimmee, Florida. Nearly 2000 attendees overflowed the Gaylord Palms Convention Center Thursday morning as the 2023 co-chairs kicked off the meeting.

During the opening session, COA welcomed back most of its former presidents and featured a video with photos from early days of action on Capitol Hill, when no one knew who the group was or understood its mission. But as COA President Miriam Atkins, MD, FACP, of AO Multispecialty Clinic in Augusta, Georgia, later explained, lawmakers would learn quickly about the lives of patients who had to drive 75 miles one way for appointments or couldn’t afford chemotherapy.

Beyond the laughs at old footage of Executive Director Ted Okon, MBA, leading a group of “dancing doctors,” a gimmick designed to grab attention, came a serious message: the MMA blindsided oncologists because members of Congress and Medicare administrators had little grasp of how community practices served patients.

As Mary Kruczynski, COA director of Development and Strategic Initiatives put it during the video, “These guys have no idea what we do.”

And so, engagement began in earnest. Today, COA is well-known in Washington, DC, and has been a resource for the Federal Trade Commission in its investigation of unfair practices by pharmacy benefit managers (PBMs). When a Senate committee recently held a hearing on prior authorization and PBMs, COA Vice President Debra Patt, MD, PhD, MBA, a breast cancer specialist who is executive vice president of Texas Oncology, testified about her recent experience of waiting 4 weeks for a peer-to-peer consult.

In many ways, its leaders say, COA retains the spirit of an upstart advocacy group, while working to look ahead at innovative technologies, care delivery trends, and other events that threaten independent practices.

“New government policies, many of which we’ll hear about at this conference, including the Inflation Reduction Act, or the Enhancing Oncology Model, are poised to change many parts of the health care system with which we operate,” said meeting co-chair Stephen M. Schleicher, MD, MBA, chief medical officer of Tennessee Oncology. “Throughout all this, constantly, the control variable as independent community oncologists, is the willingness to transform, adapt and evolve to meet the challenges of the day.”

Next came a panel discussion, “20 Years of COA: the Value of Community Oncology,” featuring Okon; Atkins; Lucio Gordan, MD, president, Florida Cancer Specialists and Research Institute; Barbara McAneny, MD, CEO, New Mexico Cancer Center, and Jeffrey F. Patton, MD, CEO of OneOncology and chair of the board, Tennessee Oncology.

The panelists agreed on several points:

• Community oncology provides care closer to patients and more efficiently, with data to prove it.
• The recent focus on health equity is old news for community oncology—practices have been helping underserved patients and those with limited resources for decades.
• Community practices are offering patients access to clinical trials and can get a trial up and running faster than counterparts in academic medicine.

“We deliver equity. We have offices everywhere,” Gordan said. “We take care of patients with all types of insurance and uninsured patients.”

He pointed to studies he co-authored that show community practices spend thousand less per month per patient compared with hospitals on cancer treatment, both for chemotherapy and for total cost of care.

McAneny said when she arrived in New Mexico as a young oncologist, she soon observed that she was seeing the same problems with the health care delivery system across many patients. In 2003, she joined an American Medical Association physicians’ committee that was supposed to advise an HHS secretary—who didn’t necessarily want their advice. McAneny said she learned that some physicians had to take a leadership role not just in treating patients, but also being their advocates.

“People don’t hand you power,” she said. “You actually have to stand up and say, ‘I’m speaking for people who cannot speak for themselves.’”

She said her mantra became, “follow the money,” and this has remained so, as McAneny has spoken out against abusive behavior by PBMs as well as data-gathering requirements from the Center for Medicare and Medicaid Innovation she worries will alarm the Native American patients she serves.

“If a patient comes in and says, ‘I have to decide between chemotherapy and putting on the table for my kids or my rent,’ we are the ones who find the money to pay the rent,” McAneny said. Hospitals, she said, typically do not offer such assistance.

Atkins agreed. She described the behavior by hospitals that have taken advantage of the 340B provision, which was intended to help safety net hospitals acquire drugs at discount prices so they could afford to care for the uninsured and other underserved patients. In her area, a hospital took over another area clinic and let all referring primary care physicians know to send patients to her competitor.

If it came down to it, Atkins said, “We will shut the door before we sell to the hospital.”

Patton said the role of COA is to give community oncology physicians a voice they lacked in other organizations. The American Society of Clinical Oncology (ASCO) is a giant organization with many constituencies, some in direct conflict with the community practice.

“In 2003 and 2004, we didn’t have a voice,” Patton said. ASCO, he said, has certain conflicts. Without COA, he said, the situation for community oncologist would be even more dire. The percentage of chemotherapy administered in physician-owned practices has been cut in half over the past 20 years, he said, despite the fact that costs are lower for payers and for patients. The financial strain on practices is enormous and constantly shifting he said.

“We have past presidents [of COA] who, not by choice but by necessity, have joined hospital systems,” Patton said.

The amount of money involved in cancer care makes it attractive to those who do not deliver care to find a way into the revenue stream, he said. “It’s a huge business, so the middlemen come in to get a slice of the pie.”

Gordan highlighted the positive contributions community oncology has made to the advancement of treatments, noting that his practice has participated in trials for 87% of the new cancer drugs approved by FDA in the last 10 years. Plus, the community practices can do this at a lower cost.

McAneny said the call for health equity—and more diversity in trials—could mean that is an important path forward for practices. The nimbleness of community practices to set up trials should be attractive to pharmaceutical sponsors now that FDA is requiring proof of diversity in trial enrollment.

“The community is an untapped resource.,” she said. As practices look for new revenue streams, trials offer opportunities for business stability along with better patient care. “As COA evolves, we will remain an advocacy organization because we have to have that voice. But we also were going to need to figure out how to teach more and more oncologists how to manage practices and how to remain independent.”