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  1. 1. 22 ONCOLOGY BUSINESS REVIEW • ONCBIZ.COM • JULY 2008 The Physician’s Role in Securing Patient Access to Appropriate Therapies: Sharing the Stage with Patients and Payers A review of a symposium held in conjunction with the American Society of Clinical Oncology (ASCO) June 1, 2008 in Chicago, Illinois By Bryan Cote 22 ONCOLOGY BUSINESS REVIEW • WWW.ONCBIZ.COM • JULY 2008
  2. 2. JULY 2008 • ONCBIZ.COM • ONCOLOGY BUSINESS REVIEW 23 THIS SYMPOSIUM WAS SPONSORED BY: This is the second installment in a series of educational symposia focusing on oncology practice issues sponsored by Biogen Idec View an exclusive webcast of this symposium at Adisconnect exists in oncology today with very few physicians having the time, data or even the comfort level to openly discuss the economics of therapeutic choices with their patients. “It’s often too difficult to fight for patients and the treatment we want for them,” admits Yoshiro Matsu, MD, an oncologist from Catskill, NY. Yet, physicians do have an opportunity to close this gap and become better advocates for their patients and assist payers in under- standing oncology’s complexities. Second in a series of sponsored sym- posia by Biogen Idec, a distinguished panel discussed solutions for policy and business issues affecting oncology practices during the 2008 American Society of Clinical Oncology’s annual meeting. Participating in the discus- sion were John V. Cox, DO, MBA, of Texas Oncology, PA in Dallas, Texas; Jeff Kamil, MD, vice president and senior medical director, Anthem Blue Cross, California; Neal Meropol, MD, director of the Gastrointestinal Cancer Program at Fox Chase Cancer Center in Philadelphia, Pennsylvania, and moderator Linda Bosserman, MD, oncologist and president, Wilshire Oncology, Los Angeles, California. The Public Payer Perspective Setting the tone, Dr. Cox shared suggestions on how physicians can be more effective advocates for their patients and practice. “Advocacy is a long-term process,” he said. “Don’t just show up when you have a prob- lem—build relationships first and JULY 2008 • WWW.ONCBIZ.COM • ONCOLOGY BUSINESS REVIEW 23 care about all of the interests at the table, including those of the payers.” According to Dr. Cox, engagement is the only way that physicians can gain the knowledge and skills to be advocates of better care. He urged the audience to consider these practical steps: Know your economic situation and•• unique mix of patients—know yourself and your situation Serve on clinical and hospital•• committees—understand your environment Read policy newsletters and•• respond to state and government as well as society requests for help— gain knowledge and be known #2 >>cont. on pg 24
  3. 3. 24 ONCOLOGY BUSINESS REVIEW • ONCBIZ.COM • JULY 2008 ASCO 2008 SYMPOSIUM REVIEW: The Physician’s Role in Securing Patient Access to Appropriate Therapies 24 ONCOLOGY BUSINESS REVIEW • WWW.ONCBIZ.COM • JULY 2008 portion of expenditures. For example, about 10% of patients are consum- ing 65% of resources. “Recognize that cancer patients fall into that 10%,” Dr. Cox explained. “Poorly coordinated end of life care is one driver of this growth. This is a big deal, and oncolo- gists are not addressing it well.” This cost escalation is placing greater pressures on oncologists to demonstrate improved outcomes and quality of life for their patients. Payers, he added, are sensitive toward costs and overutilization of imag- ing, end-of-life technology, and drugs that are used beyond evidence-based guidelines. Because of these pressures, oncologists are often challenged in securing patient access to appropriate therapies. “Participation in quality improve- ment programs, such as the ASCO Quality Oncology Practice Initiative (QOPI) is important for you to dem- Participate in state meetings—•• know the players Know your legislators, communi-•• cate with them and participate in campaigns—be a resource for them and their health liaison Oncologists, said Dr. Cox, need to frame issues around their patients’ experience. “Use their stories and your practice data to explain the com- plexity of care,” he said. Oncologists’ involvement will become more impor- tant as public payers turn their attention to the cost of cancer care. For example, healthcare spending has grown faster than the gross domestic product (Fig. 1). This escalation is placing greater pressures on the quality of cancer care provided by oncologists’ at the most critical stages of the disease. A small portion of patients in the health care system drive a significant onstrate your willingness to evaluate your practice and report on measures that are important to payers (and patients),” Dr. Cox said. “In advocat- ing for change in a policy or for access to a therapy, speak to the interests of your patients.” Taking sides is not a solution. He advised, to advocate for access—and to succeed for patients—physicians should not look at issues as commu- nity versus academia, or one specialty versus another. “Resist painting every statement as the end of oncology as you know it—that will close doors, not open them,” he further added, “Partner with groups beyond your self-interest such as nursing or patient advocacy groups, because in advocacy, the house of medicine stands as one.” A Case of Local Advocacy Success Access to care is not affected by national or CMS policy alone. State John V. Cox, DO, MBA, Texas Oncology Figure 1. Healthcare Spending. Source: CMS, Office of the Actuary, National Health Expenditure Accounts, 2006 20% 18 16 14 12 10 8 6 4 2 0 1965 1975 1985 1995 20051970 1980 1990 2000 2010 2015 HealthspendingasapercentofGDP Actual Projected All public spending Total health spending All private spending Medicare spending
  4. 4. JULY 2008 • ONCBIZ.COM • ONCOLOGY BUSINESS REVIEW 25 THIS SYMPOSIUM WAS SPONSORED BY: >>cont. on pg 26 JULY 2008 • WWW.ONCBIZ.COM • ONCOLOGY BUSINESS REVIEW 25 legislatures have become more active in trying to control healthcare bud- gets and issues. Coverage decisions by a state board of insurance or a policy by a state health agency may make it harder for practices to deliver care. “This decreases patient access,” he said. “Being involved in your state oncology society is very important, both to be aware of these issues and to be available to tell your story.” Involvement in state societies is also important for oncologists to advocate for local Medicare coverage decisions. Each state has a Carrier Advisory Committee, and each state oncology society has a seat at the table. Since 2004, Medicare has reor- ganized contracted carriers into more compact regions. “You can work with these committees on edits to get paid for coverage for your patient’s treat- ment in your region, so go to your state affiliate,” urged Dr. Cox. KEY POINTS • Oncologists must be involved in advo- cating for patients’ access to quality, evidence-based oncology care. • Effective advocacy hinges on building relationships with policy makers at all levels of government. • Recognize that state legislatures are becoming engaged with healthcare spending and oncology. • Join and get involved in your state oncol- ogy society. Make sure your state’s Medi- care Carrier Advisor Committee’s oncology representative knows your concerns. A View from a Health Plan Dr. Jeff Kamil, vice president and senior medical director for Anthem Blue Cross, provided an economic perspective on the cost of cancer care from a health insurer’s perspec- tive. He informed that about 11% of Anthem’s commercial members drive about 43% of total medical costs. “That 11% includes chronic conditions including diabetes, COPD, and conges- tive heart failure, but unfortunately doesn’t [include] cancer—it should,” explained Dr. Kamil. “[Of the] 1% of our membership that’s driving 28% of our total medical costs, many of those people have cancer.” So how can a physician advocate for patients and secure access to appropriate therapies when the payer doesn’t even have the disease on its radar? “It’s a fair question,” Dr. Kamil said, “and part of the answer stems from the fact that we don’t really understand oncology. It’s a complex specialty with a major impact on med- ical costs.” Consider the cost of oncology in the payer’s terms: Anthem collects around $200 to $300 from each commercial member per month, and a single diag- nosis of cancer diagnosis takes $50 to $100 of that income. “If you roll that out, we’re paying about $200 million a month for cancer,” he said. Figure 2 shows how much the can- cer-member-per-month represents the total per-member-per-month (PMPM) costs across six states, together with the increase in costs from 2005 to 2007. In addition, specialty pharmacy oncology drug spending is on the rise. Specialty drugs are the largest category driving total drug trend. In 2006, specialty spending increased 16.1% for Anthem, utilization of these drugs grew 7.3%. Historically, Dr. Kamil pointed out, health plans’ approach to oncology has been to contract for the best deal. Furthermore, he iterated that health plans have not had the required pro- fessional or technical expertise to engage oncology care. Oncology is a complex field with many disease stages and treatment options and like all other parts of the health- care system the disease has its share of overuse, underuse and misuse of drugs. However, health plans can no longer continue to ignore cancer, since oncol- ogy is a ‘trend driver’ especially with regard to safety and off-label use. Addressing the future and where the cost, quality and physician dilemma is headed, Dr. Kamil pre- dicted that health plans will want to: Better understand the needs of•• oncologists and their patients— which suggest that Dr. Cox’s advocacy ideas are that much more important. Help oncologists to provide•• higher quality cancer care but use resources in a more efficient way.
  5. 5. 26 ONCOLOGY BUSINESS REVIEW • ONCBIZ.COM • JULY 2008 ASCO 2008 SYMPOSIUM REVIEW: The Physician’s Role in Securing Patient Access to Appropriate Therapies 26 ONCOLOGY BUSINESS REVIEW • WWW.ONCBIZ.COM • JULY 2008 of healthcare costs as part of gross domestic product as a bad thing,” said Dr. Meropol in the evening’s third presentation. “But we’re in the innovation business and from a pure economic standpoint, it may not be a problem in the short term. However, insofar as increasing costs may result in disparities in care, there are serious concerns.” As physicians weigh how to become involved in advocacy and secure pay- ment for the treatment regimen they believe will improve a patient’s quality or length of life, they must under- stand the impact in economic terms for the patient (ie, paying for care and treatment). Dr. Meropol referred to a Kaiser Family Foundation study reported in USA Today (Nov. 2006) of households affected by cancer in the past 5 years in which 46% of To accomplish this, health plans will insist that oncology care be evidenced-based and will develop administrative tools to enable this (for example, the NCCN guide- lines—developed as algorithms— encompass 97% of the tumors encountered in oncology practices). Collaborate and develop new pay-•• ment systems with oncologists that will reward oncologists who pro- vide evidenced-based, quality and cost-effective care. On the horizon, Dr. Kamil con- cluded, Anthem is working with oncologists to develop new tools and relationships that will improve health plan and oncology interfaces and relationships. KEY POINTS • Health plans including Anthem need to be better educated on complexities of oncology. • Oncology spending, including specialty drug utilization, will be increasingly targeted by private payers; Anthem collects around $200 to $300 from each commercial member per month, and a single diagnosis of cancer diagnosis takes $50 to $100 of that income. • Health plans in the future will need to de- velop new systems to reward oncologists who provide evidenced-based, quality and cost-effective care. Discussing Economic Cost with the Patient For all the debate and angst over rising oncology costs, there’s a differ- ent point of view to consider in this debate: Is this increase all bad? “We always talk about the rising slope Figure 2. Treatment-Condition Pairs. Source: Source: Anthem Blue Cross. Reprinted with permission. Dr. Jeff Kamil, MD, Vice President and Senior Medical Director for Anthem Blue Cross We welcome your comments on this article and topic. Send an e-mail to Cancer PMPM related to Total State PMPM 400 $300 $250 $200 $150 $100 $50 $- 350 300 250 200 150 100 50 24% 25% 13% 15% 15% 16% 17% 15% 16% 17% 15% 20% 21% 20% 17% 19% 16% 25% 05 06 07 05 06 07 05 06 07 05 06 07 05 06 07 05 06 07 0 VA is Paid $, all other states are Allowed $ 07 Total PMPM 05 Cancer PMPM NY VA GA CT ME NH
  6. 6. JULY 2008 • ONCBIZ.COM • ONCOLOGY BUSINESS REVIEW 27 THIS SYMPOSIUM WAS SPONSORED BY: >>cont. on pg 28 JULY 2008 • WWW.ONCBIZ.COM • ONCOLOGY BUSINESS REVIEW 27 Closing this gap is not easy. For one, physicians admittedly strug- gle to discuss cost with patients. For example, a study titled “Medical Oncologists’ Views on Communicating With Patients About Chemotherapy Costs,” (Journal of Clinical Oncology. 2007;25(2):233-237), indicated that almost two-thirds of 167 physicians surveyed refer patients to a third party when recommending high-cost treatments and 46% of the 167 some- times or always omit discussion about costs of very expensive treatments when they know the cost will finan- cially strain the patient. “Oncologists have a responsibil- ity to help patients integrate cost into treatment choice,” said Dr. Meropol, who concluded his presentation with information on a new ASCO initiative to help physicians who are struggling in their new role. Meropol is a member of the ASCO Cost of Care taskforce. The taskforce is working on several projects to help provide guidance to physicians on the importance of discussing cost with patients, and pro- 930 respondents were patients with cancer. Of those households: 50% of patients either used up all or most of their savings, borrowed from rela- tives, or sought charity; 13% made treatment choices based on cost. And, 27% of those who were ever unin- sured, as Figure 3 illustrates, delayed or decided not to get care at some point for cost reasons. Evaluating monetary cost is a new component for oncologists and gaps remain in how to address it. In a 2003 article that appeared in the Journal of the American Medical Association (JAMA. 2003;290:953-958) titled “Patient-Physician Communication About Out-of-Pocket Costs”, 79% of 133 internists surveyed said they think patients want to talk about costs and 63% of 484 outpatients said they also want to discuss costs, yet only 35% of the physicians and 15% of the patients had ever carried out the discussion. vide tools for patients and physicians to help facilitate these discussions. KEY POINTS • Oncologists have a responsibility to help patients integrate cost into treatment choice. • Patients generally want to discuss the high cost of care/treatment, yet few physicians and even fewer patients actually have this discussion. • New ASCO Cost of Care taskforce is addressing issues raised by the high cost of cancer care for physicians and patients. Closing Remarks In closing remarks, Dr. Linda Bosserman, MD, of Wilshire Oncology noted how electronic medical record (EMR) data will give physicians a great tool to advocate for their patients. Wilshire Oncology instituted an EMR system eight years ago and has used it to track its patients by cancer type, stage, and delivered therapies. For example, Wilshire saw 1,903 patients with breast cancer in 2007, 623 in stage II and 659 in stage III. Figure 3. Cost-Based Treatment Decisions. Source: National Survey of Households Affected by Cancer, USA Today, Kaiser Family Foundation, Harvard School of Public Health, 2006. Dr. Neal Meropol, MD, Director, Gastrointestinal Cancer Program, Fox Chase Cancer Center Ever delayed or decided not to get care for cancer because of the cost Ever chose one cancer treatment over another because of the cost 8% Total Ever uninsured Always insured 27% 5% 4% 13% 3% Percent Reporting that They/Their Family Member Did Each of the Following...
  7. 7. 28 ONCOLOGY BUSINESS REVIEW • ONCBIZ.COM • JULY 200828 ONCOLOGY BUSINESS REVIEW • WWW.ONCBIZ.COM • JULY 2008 ASCO 2008 SYMPOSIUM REVIEW: The Physician’s Role in Securing Patient Access to Appropriate Therapies Figure 4 shows Wilshire’s top eight cancer diagnoses by stage. Armed with data like this, an oncology prac- tice can more easily educate payers like Anthem on the cancer treatments and care being provided to the insur- er’s members, along with associated costs and outcomes. For example, the EMR data show that most patients received cura- tive therapy. According to Dr. Bossermann, “That’s an impor- tant discussion to have when you go to payers—work with them so they clearly analyze and pay for care in the cost-effective outpatient oncology clinic setting managed by medical oncologists. This would min- imize wasteful administrative costs on both sides and unnecessary emer- gency room, hospital, and outside vendor care that does not improve outcomes.” At issue, however, is that very few physicians overall have access to elec- tronic medical records in the United States. “High quality data is needed to formulate evidence of the best approaches to high quality, effective care,” said Dr. Bossermann. Without this data, oncologists, she surmised, will be powerless to improve access and ensure appropriate payments for the care they deliver. Health plans, meanwhile, will remain without the detailed data they need to support the value of delivered care. KEY POINTS • Armed with electronic medical record data, an oncology practice can more easily educate payers, advising them, for example, on the number of patients receiving specific types of therapy for specific tumor stages and features. • As the number of factors increases which determine best therapy, EMRs become the most cost-effective solution to prompt and collect therapy decision data at the point of care. • Oncologists will be powerless to improve access and sustain their cost-effective delivery models unless they have evidence to support the value of delivered care. Linda Bosserman, MD, FACP, President, Wilshire Oncology Figure 4. Stage of Top 8 Cancers in 2007. Source: Wilshire Oncology. Reprinted with permission. Stage of Top 8 Cancers in 2007 Stage Breast ICD9: 174- 174.9 & 233 Colon ICD9: 153-153.9 Lymphoma ICD9: 200.2–202.9 Lung ICD9: 162-162.9 Prostate ICD9: 185-185.9 Rectal ICD9: 154-154.9 Ovary ICD9: 183-183.9 Melanoma ICD9: 172-172.9 0 271 7 - - - 5 - 7 1 659 45 41 71 - 20 24 22 2 623 90 43 24 114 24 7 15 3 187 55 41 49 16 31 50 9 4 45 33 78 71 35 14 12 7 No Stage* 118 20 37 25 62 13 14 30 Total 1,903 250 271 240 227 107 107 90 (*TNM came from previous EMR 12/04, Stage didn’t populate but is entered)
  8. 8. JULY 2008 • ONCBIZ.COM • ONCOLOGY BUSINESS REVIEW 29 THIS SYMPOSIUM WAS SPONSORED BY: JULY 2008 • WWW.ONCBIZ.COM • ONCOLOGY BUSINESS REVIEW 29 Final Thoughts As discussed by each of the pre- senters, there are significant opportunities for the oncologist to get actively involved in securing patients’ access to optimal therapies. Payers, pharmaceutical companies and pro- viders will need to work as a team to communicate with patients and help them get the most cost-effective care. Moreover, as suggested by Dr. Bosserman, high-quality data from electronic medical records is needed to formulate evidence of the best approaches to high quality, cost-effec- tive care. For all the cost challenges of cancer care, the panel concluded with the opinion that public payers such as Medicare and private payers will no doubt escalate initiatives to pay for effectiveness and innovation and not for therapies that lack a demonstrable cost/benefit ratio. BC View the complete slide decks and hear the speakers’ presentations in a webcast of this symposium at For more information on Biogen Idec products please visit the Biogen Idec website at ASH ‘07: How Does Drug Pricing Drive Therapeutic Choice? The content and views presented in this symposium are those of the faculty and do not necessarily reflect the opinions or recommendations of Biogen Idec or OBR. ASH ‘08: To Be Announced ASCO ‘08: The Physician’s Role in Securing Patient Access to Appropriate Therapies This is the second installment in a series of educational meetings being held at ASCO and ASH. These meetings are sponsored by Biogen Idec. For free reprints of this series contact your local Biogen Idec representative. To view current or archived webcasts of this series visit We look forward to seeing you at our next installment in this series at ASH ‘08 in San Francisco, CA.