From Getting Paid to Managing Burnout, Panel Examines Future of Community Oncology Care

Value-based oncology care is here to stay, with or without leadership from CMS, because commercial payers and patients have seen its benefits, according to leading practice administrators who took part in Thursday’s discussion, “Building/Designing the Community Oncology Practice of the Future,” during the 2022 Community Oncology Conference, presented by the Community Oncology Alliance (COA).

Barry Russo, MBA, CEO of The Center for Cancer and Blood Disorders, moderated the session that featured Glenn Balasky, executive director of Rocky Mountain Cancer Centers; Jeff Vacirca, MD, FACP, CEO of New York Cancer & Blood Specialists; and Emily Touloukian, DO, president of Coastal Cancer Center.

Russo asked for predictions on the future of reimbursement, and Balasky said CMS’ decision to let the Oncology Care Model (OCM) expire without a replacement will create “an awkward transition,” because the OCM helped propel movement away from fee-for-service (FFS) reimbursement.

“I see a future where the private payers want the benefits of value-based care,” Balasky said. After years of experimentation with the OCM, some payers were taking steps such as paying for advanced care planning. Data collection from OCM patients will help practices show payers how value-based care worked in their favor, he said.

The challenge now will be finding ways to retain momentum. “We’ve got to keep on this path,” Balasky added.

Vacirca said the next step is to work with employers to demand movement away from FFS toward payment for episodes of care. Among insured patients in New York, he said, 90% are dealing with a payer that is a third-party administrator (TPA) of their plan—and in these cases, there’s no incentive to cut premiums.

“If they drive premiums down as the TPA, they make less money,” Vacirca said. “You’ve got to get to the employers, because the employers have no clue whatsoever that the payers are working contrary to what are their best choices.”

Together with reimbursement frameworks are the challenges of prior authorization, which clinicians report are more cumbersome than ever. Balasky said his practice just hired a staff member to work solely on payment for genetic testing, because so many patients have been billed for this despite the growing role of precision medicine in cancer care. Vacirca said he’s interested in how Texas’ new “gold carding” law could set a standard that eliminates prior authorization for practices that can show more than 90% of their requests are approved.

Unfortunately, Balasky said, too many payers have created incentives with brokers to build in utilization review and other steps that prevent quick payment for services. “The challenge I see, from my conversations with the insurance industry, they have built a piece that they can't untangle,” he said.

Russo recalled a conversation with Vacirca on how this system forces practices to add staff and systems to keep payments flowing despite the barriers. “Revenue cycle management is the lifeblood of our practice,” Russo said.

Site of service. Russo shifted the discussion to a trend that took hold in the pandemic, in which practices are pressed to offer infusion in patients' homes. The panelists agreed this creates safety risks if physicians see patients less frequently, and it’s an inefficient use of nurses’ time.

“It’s not really clear that there are actually cost savings, to the system or to the patient,” Touloukian said. A patient in the clinic is evaluated for iron levels and clinicians gain more insight into adverse events, which help prevent hospitalization.

“Something that community oncologists really excel at is bringing that sort of home experience into the clinic,” she said. “It's one of our strengths.”

Both Balasky and Vacirca said the trend is rooted in a lack of attention to total cost of care and battles over which parts of cancer care are charged to a patient’s medical plan vs a prescription plan.

“In vertically integrated systems, it’s another way for the pharmacy benefits managers [PBMs] to bring in infusions onto themselves, to charge them back to the employers for huge amounts of money and then not be transparent about any of it,” Vacirca said.

Russo then asked about the future of telemedicine, and Touloukian said it will remain part of the landscape but perhaps be used differently than it was during the pandemic. For example, the ability to consult multiple family members on a telemedicine call to discuss a cancer patient’s treatment plan can be beneficial—Touloukian has helped members of her own family this way.

Remote monitoring will also evolve, as some patients appreciate extra contact while others don’t want to be bothered. The value of such contacts must be made clear in advance, Balasky said. Vacirca pointed out that remote monitoring is a more modern term for all the times physicians have been interrupted with questions and issues that come up between visits.

For years, doctors called patients after 5 pm to go over test results. “You’re missing your kids’ ball games, missing ballet, and getting home at 8 o’clock,” he said. “We’ve done this our whole careers. Finally, there’s an opportunity for us to actually continue what we’re doing, to have that patient connection, to see the patient at the same time and get paid something for the work we do.”

Marketing community oncology. As consolidation and vertical integration drive up costs elsewhere, community oncology needs to find new ways to highlight its value.

“One of the things we learned through the pandemic was that we needed a better way to communication with patients,” Russo said. Digital solutions to telling the story are necessary, as new competitors such as CVS Health and Optum enter the market. Vacirca said other community practices are being seen as collaborators and perhaps future partners, given the headwinds. “How do we grow and become more successful together,” he said.

Balasky sees the major academic centers as offering complexity at a time when consumers want more simplicity. But community oncology needs to do more to communicate its value within local markets, and Russo agreed that more must be done with tools such as search engine optimization and social media to make sure practices get noticed.

There’s a good story to tell, Vacirca said, but until now, lack of transparency has made this difficult. “We just got transparency on premiums,” he said. “There’s no transparency on payers. The employers are waking up and realizing this.” Even his own practice is learning this. For years the group had coverage through UnitedHealthcare; this year, after a switch to self-insurance, “the first thing we did was take the PBM out of the equation,” and managed drugs directly. “As an employer it took 20% to 30% off the top.”

Personnel and burnout. Russo said the pandemic has offered new lessons to oncology practices, including the value of well-being. He spent the final minutes of the session on mental health among clinicians and the difficulty practices have finding staff. The generation of physicians trained in “work, work, work until you drop dead” is giving way to a new one that demands more attention to family and life priorities.

Mental health is “incredibly important” in community oncology, Touloukian said. “It’s going to look different for everybody,” she said, "not just from practice to practice but for each individual.”

Practices cannot wait to hear from staff about scheduling problems or the need to work from home—they must go out and actively engage with the staff, she said. Russo said his own view has shifted. “We do have to figure out going forward, how do we manage that work-life balance, and what we do to assist them?”

Vacirca said changing culture includes empowering staff to communicate about the need for change. It can be as a simple as picking a different staff member each day to engage in a discussion about how they are doing. “You’ll get to know every single person there. And that's how you change culture. And that's how you create connections.”