However, Mr. Okon cautioned that the PPACA “is actually pushing the private payers to move very rapidly, and we are seeing a lot of changes on the private payer side,” such as increasing patients’ share of costs.
SGR reform
Dr. Lichter encouraged oncologists to think of offering some form of robust quality performance measurement as a means of resolving the SGR impasse. They could show that they are practicing oncology medicine in a way that is cost-effective, that they are measuring their performance, and that they have the numbers to show it. For instance, early experience with the oncology medical home has proven that it is possible to document improved outcomes, such as fewer hospitalizations, he said.
“Unfortunately, we are still in a cycle of short-term fixes” for the SGR, Mr. Farber said. A long-term fix is unlikely in 2011, and physicians will probably have to wait until the end of the year to learn the details of the next patch. The problem is the cost, which now stands at $300 billion. “It is too expensive to fix and has become one giant accounting error at this point,” he said. “We can’t handle a 25%–30% reduction in our Medicare rates, and I don’t believe Congress would allow that to stay on the books. The big question is, what will they replace it with? A 0% update, a 1% update, or a negative 1% update?”
Measurement of quality
At present, roughly 20 groups claim to be the arbiters of oncology quality measurement. All of the panelists agreed that physicians need to play an active role in devising and running a quality program. “We are all going to be measured, and the results of that measurement will be made public,” Dr. Lichter noted. “There is a compelling reason for us to unite behind a quality program in which we all participate and to make that the standard,” he asserted. “It should be physician run and physician directed. We are the only group that can truly judge physicians’ quality.”
He said that ASCO’s Quality Oncology Practice Initiative (QOPI), which allows oncologists to compare the quality of their care with that of their peers, is limited by its retrospective and labor-intensive nature. But with the conversion to electronic records, it could provide information in real time and even be used for decision support.
Mr. Farber agreed with Dr. Lichter, but added that “the hard part, especially in oncology, is to define quality and a valuable treatment. You might provide…the highest quality of care, yet the patient outcome might still be negative.”
Mr. Okon said although the community oncology model is efficient, “the onus is on us to prove it.” Here, the medical home model is getting attention, with its dual emphasis on quality and efficiency. It shows that there can be an increase in quality concurrent with an increase in efficiency and cost-effectiveness.”
Workforce issues and access to care
There are no direct efforts under way to increase the oncology workforce, according to Dr. Lichter. “We’ve got to learn how to care for patients with the number of people we have,” he said. Physicians are not trained in process improvement and are hard-pressed to find time to analyze their workflow, but doing so will be critical, he commented.
Mr. Brow predicted that “practices are going to have to see more patients per physician to stay in the same place,” given the growth in the Medicare population and the lack of corresponding growth in the oncology profession. To meet this objective, he endorsed the use of physician extenders, such as physician assistants and nurse practitioners, and a structured approach to improve the efficiency of the practice, such as working unconventional hours or doing workflow analyses and revamping staffing models. Applying Lean Six Sigma principles, which have been used to boost efficiency in other industries, could also go a long way in this regard, he added.
But Mr. Okon contended that regardless of oncologists’ numbers and efficiency, patients’ access to cancer care might well boil down to the extent of their insurance coverage. He predicted that underinsurance would be an unintended consequence of the new healthcare reform. “It is going to be a crisis point in oncology, because…we are seeing the private payers already reacting to healthcare reform so that there is going to be more burden on the individual.”