State of Cancer Care in America
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Dr. Blase Polite discusses the latest State of Cancer Care in America report, and the opportunities and challenges confronting the cancer care community.

Read the related article "The State of Oncology Practice in America, 2018: Results of the ASCO Practice Census Survey)" on JOP

 

Support for JCO Oncology Practice podcasts is provided in part by AstraZeneca, dedicated to advancing options and providing hope for people living with cancer. More information at AstraZeneca-us.com.

Welcome back everyone to the ASCO Journal of Oncology Practice podcast. This is Dr. Nate Pennell, medical oncologist at the Cleveland Clinic and consulting editor for the JOP. It's that time of year again, when ASCO releases their annual report titled The State of Cancer Care in America, which has a goal of increasing awareness among policymakers and the larger cancer community about opportunities and challenges in the delivery of cancer care for the United States. The 2017 version is being released this month, and is always one of the most popular manuscripts and, to be honest, one of the most popular podcasts we do here at the JOP.

Joining me today is Dr. Blase Polite, associate professor of medicine and deputy section chief for clinical operations, as well as the executive medical director for cancer accountable care at the University of Chicago. Dr. Polite is a past chair of both the ASCO cost of cancer task force and the government relations committee, as well as being a fellow of ASCO. Today we'll be discussing the State of Oncology Practice in America, 2017, Results of the American Society of Clinical Oncology Practice Census Survey. Dr. Polite, thanks for joining me.

Nathan, good morning. It's great to be on with you again.

So why don't we start out just by talking a little bit about the background and the purpose of this annual State of Cancer Care in America report. How does ASCO get this data, and really what's the intended purpose?

So we're very excited this year. There's actually been a change to the way we do things. So in addition to the standard survey that we send out the practices, we've also been able through the work of our excellent team at ASCO to use something called the physician compare website and database from the Center for Medicare and Medicaid Services, CMS, that allows us for the first time to really get a sense of the true number of oncologists practicing across the United States, where they're located, how big their practices are, et cetera. So now we have two sets of data, one that gives us a nice sense of the geography of the total census of care of practices, and then our more detailed in-depth look of our survey practices.

And you know, this is really one of the most important things for those of us who work at the ASCO level, because this gives us a true pulse of what's going on out there, what are the market trends, and really, most importantly, what is it that is bothering practices on a day to day basis that we at ASCO then can try to figure out from a policy standpoint, can we work to make things better?

So one of the things that the State of Cancer Care in America always does is look at sort of the demographics and the makeup of the different practices. And have there been any significant changes this year? And is this something that is part of a trend, or anything that surprised you?

Well, the one thing that we continue to see, and we've gone back to 2013 and we've looked at the numbers of the-- using the physician compare, where we really get a sense of all of the oncology practices out there, is we're starting to see more and more consolidation. And specifically what I mean by that is we continue to see more oncologists every year, but a fewer number of total practices. So again, we're beginning to see more practices consolidate into larger groups. Not surprising, given the economic pressures and everything else that we see. But that that's probably a more consistent trend that we're seeing over the years.

Well, that certainly makes sense, I think, with the payer issues. And that kind of brings us to our next part here. One of the main purposes of this is for oncology practices to be able to list their top sources of pressure and concerns. So can you talk a little bit about what the concerns of the oncology practices were for 2017?

Yeah. So we were able to look at concerns within the census, both at an overall level, and then we're able to look at it specifically by how we break up the practices, which are academic, hospital, or health system owned, and physician owned. And what shop really to the top this year and wasn't really even a contest, was payer pressures. So this is the one thing that people are screaming from the rooftops, 70% of practices were physician owned, and really over half of other practices are saying that payer pressures are the biggest thing.

And then when we do payer pressures, we ask practices specifically what do they mean by payer pressures. And again here you look at the three things. They all kind of follow the same thing. The number one is prior authorization. Number two is coverage denials and having to do appeals, and number three is these peer to peer requests from medical directors. So these are the things that are bothering every single practice out there, and is really rising to the top.

In fact, we also then ask, well tell us about the resources you put forward in order to deal with the prior authorization. And we find on average practices have six full time equivalents dedicated just to doing prior authorizations. And we have one practice that has over 100 people dedicated to doing that. I know at the University of Chicago we have a dedicated group of about 30 to 35 whose only job is to deal with prior authorizations. So this is one of those things that I think we all feel. It frustrates everybody, and it's clearly something that will become a major focus for ASCO to figure out how can we find a better system.

I know that certainly resonates with me, and I'm sure all of our listeners. This is not going to be a surprise to them. We also have a, I'm sure, a fairly large group that does this at the Cleveland Clinic, but even the prior auths and peer to peer requests that make it through that layer are incredibly disruptive. I find it hard to imagine how individual practices that can't afford to hire people are dealing with this. And I guess that probably feeds into this consolidation that you are seeing.

Yeah, absolutely. I mean, I think that's a major part of it. And so one of the things I want to highlight is we are beginning this year with trying to turn the State of Cancer Care in America into a living sort of document, and what I mean by that is instead of just the once a year publication, within the Journal of Oncology Practice we are now going to have a state of oncology care series, and that will be both invited commentaries specifically addressing the things that our members are telling us are a problem, as well as looking for original research that we think answers and helps provide actual data to support some of the things that concern us.

And so it won't be a surprise to anybody that one of the first things coming out of the gate is going to be the issue of prior authorization. And what we've done there is we've invited Mike Colosia, who used to run the oncology business Aetna, and Lee Newcomer, who was recently retired from United Health, both very good friends of ASCO, both very, very thoughtful, as well as we're going to have a commentary on the physician side to really go at this question of why do they do it? What are some of the alternatives to it?

Because I think what you find when you get into these discussions is nobody likes prior authorizations. Insurance companies do it because they feel that there are times where we are doing things that are not supported by the evidence, and it clearly has some money saving to them. But if you really push them, they don't like the fact that they have to hire a lot of people to do this, and they would like a better system as well.

Yeah, definitely kudos at ASCO for making an effort to trying to do something about this and not just report on it. This is clearly over the last several years becoming more and more of an issue. Everyone complains about it, but it's hard to know on an individual basis what you can do about it. So I'm looking forward to those papers.

So in past years, one of the major perhaps, you know, in some years, I know even the top concern was dealing with the electronic health record. And it seems like it's fallen down a little bit this year on the list. I don't know if that's because we're actually making progress with interoperability and people are becoming more comfortable with that, or if it's just that other issues are becoming more pressing.

Yeah, I'm sure it's a little bit of both. But there's no question that when we look back from 2015 to now 2017, each year we've seen an improvement. Back in 2015 electronic health records were about 45% of people listed that as their top concern. You know, this year that number looks more like 35%, 30%. And when we dig a little bit deeper into the electronic health record issue, and what we find is probably the satisfaction that people are getting is from the interoperability.

And specifically I think it's interoperability within a EHR system. Meaning, you know, for example, University of Chicago, we're on the Epic system, and in the last year I have finally been able to actually view records, notes, radiology reports, pathology reports, from any other center that is within the Epic system. I still can't view records from another system, which again, I think remains a source of frustration to everybody.

But just that improvement has been the one that I think it's been helpful to everybody, and it just saves so much time, especially these days as the original pathology report was amended 14 times as we get all of our next generation sequencing, et cetera, so the records that you get don't tend to have all that, just to be able to go and sort of pull that information has been helpful.

I think the other thing is there's a learning curve. And I think, as we've interacted with the electronic health record more, people have learned the tricks and some of the shortcuts and some of the ways to move it beyond just being an electronic version of the paper chart. Now interestingly, when you take a look within our different sort of systems, who rates electronic health records as a problem, the community practices actually are the most satisfied, and the academic doctors are the least satisfied.

That sort of rings very true to me, and I think part of that is more the learning curve issues. I think the community physicians who are in clinic on a more regular basis have really learned to start making electronic record their friend, but I think the academics who don't spend as much time in clinic have not taken the time, I think, to really learn how to optimize their use, and so remain a little bit frustrated by all the clicks and other things that are required, and I think some of them, if you took them in a dark room, would say, gee I would love to go back to paper records where I could just scribble things on the back of a sheet of paper and I'd be done.

But no, I think we're making improvement here. But again, this is another area that ASCO has been very, very conscious of, have been working very hard with the electronic health record vendors, so again, you will see a set of articles coming out in JOP looking from the vendor perspective, so we can get their sense of what they think they're doing well and what they're not doing well, and then from some of our experts, clinicians who really know the health informatics side of the world, people like Deb Pratt and Linda Wasserman, who really have delved into these issues and kind of given the perspective from the clinical side.

I'll say the other group that is very frustrated about what's going on with EHRs and there continues to be a lot of activity, is Congress. So as you know, ASCO, we spent a lot of time with the congressional committees, and they realize that in some ways they helped create this mess of lack of interoperability. You know, in 2008 with the Affordable Care Act, a lot of money was put in by Congress, taxpayer money, to really get practices on electronic records. But I think what they will admit is they wish they put more strings to that, and more requirements that they work together, you know, et cetera. And they didn't. And they're angry by a little bit of the foot dragging.

And so I think everybody would like us to get to a system, you know, as I say, very similar to what all of us experienced who have traveled around the world, that I have an ATM card and I can be in the middle of a rural village in China and put my card into an ATM machine, and somehow or another it finds my bank and gives me local currency. But the fact that I can't see the electronic health record of a facility across the street from me when I'm at the university just doesn't make sense and doesn't ring true to us that there are major barriers to that.

So we suspect it's more competitive pressure, and that it's going to require federal and congressional mandate to say we gave you taxpayer dollars to build this infrastructure, you certainly are making a good living off of it, now you have some responsibility to help the ecosystem out. So again, we will continue to push that pretty hard at our level.

I certainly recognize this frustration in my own practice, and I have the same experience using Epic that the Care Everywhere function, when I work with places that have a similar one, you can suddenly see the real potential of interoperability, and how really seamless it can be of transitioning care from place to place.

But then I see a second opinion of someone who goes to a hospital across the street and suddenly I've got a substandard paper record of a print out of 100 sheets that usually don't have the most recent updates of the pathology reports and the doctor's note, and you're suddenly back in the 20th century again. So I'm glad to hear that things are moving forward with that. I think we're experiencing-- the challenge of trying to fix something after the fact is always harder than it would have been to do it right the first time, but at least making efforts in that direction.

So we talked about EHR, we talked about payer pressures, are there any other significant sources of pressure that the practices were reporting that are worth discussing?

Yeah, I mean, I think the other one, and this is the one where we see much more for the private practices, so it's practice expense and drug prices. So we're beginning to see that rise more and more to the top. And again, goes back to our talk about consolidation, that as these drugs get very, very expensive, I think what all of our listeners hear, but maybe people who aren't involved in day to day don't understand is when you hear about these $100,000 price tags, et cetera, this also represents inventory that practices have to keep on hand, and have to manage, and as more and more payers are squeezing what they're paying for the drugs and the margin on drugs, it's becoming more and more of a liability for practices. So I think that is clearly something that the private practices are telling us.

The academic practices, the staffing issues, and I believe that the two are actually probably the same issue. Academics who don't see the books, and a lot of them don't have to deal with that don't realize the expense pressures, but where it's plain in is in hiring nurses and advanced practice providers, the dollars are squeezed. And we're all getting pressure because the dollars are squeezed, and so every hire has to be justified. So, you know, I think the academics are seeing it that way.

And then one final question that was on the survey, was they asked practices if they were ready for the Medicare merit based incentive payment program, or MIPS program. And about 58% of practices reported being ready, and a certain percentage said that they were at least partially ready. Do you think that sounds like good progress at this point?

This is one of those numbers that's in the eye of the beholder. I actually looked at those numbers and was quite impressed, and specifically, again, when we break that number down by practice type, what I'm most happy about is that our private practices, about 75%, 74%, 75%, reported being ready prepared for MIPS.

That actually was a group that I was probably the most worried about, given the complexities of trying to understand this. And again, I give strong kudos out to ASCO, as well as others who have been focusing on MACRA and MIPS like a laser beam from the second that the legislation was just a twinkle in the eye of the congressional committees, to its passage, to the writing of regulations, and we have spent pretty much every year at ASCO, and the best of ASCOs of doing town halls, going through these issues. Many of us have been going around the country to state societies and really emphasizing, and strong kudos go out to Steve Grubbs and the entire clinical practice affairs division at ASCO, who have put together some really wonderful tools to help practices extract things from the electronic record in order to be able to do MIPS.

So I'm actually very encouraged by what I see on the private side. On the academic side and the hospital owned side, I suspect that the number is actually underreported slightly, because again, if you're part of a large, multi-specialty group, you're not able under MACRA and MIPS to sort of single the oncology group out.

And so what tends to happen is most of this gets taken care of at a much higher or more distant level from you, and it's likely that the quality metrics that are reported have nothing to do with cancer. They're reporting on blood pressure control and immunization and hemoglobin A1C. So I think a lot of academics and hospital owned physician groups probably don't see the work that's being done, because it's being done for them. But the groups that have to do it because there is no plan B, the private groups, I think are doing a good job.

Certainly ASCO has done a great job of trying to educate everyone about this, and continues to do so. So if you're encouraged, I'm encouraged. So can you just give us maybe some take home points for 2017 State of Cancer Care for America, what you'd like our listeners to take home from this report?

In terms of take home, again, I think what we're hearing very loudly are the payer pressures and the issues that remain with the electronic health record. And so we hear that loud and clear. And those are issues that we're going to continue to work on. Again, I really want to encourage all of our listeners here to stay alert for anything that is branded as part of the State of Oncology Care in America, they're called SOCA. We will be branding those things within the JOP, so both, again, invited commentaries from thought leaders to help us.

And again, the way we're inviting them is really focused on I don't want a high level academic discussion, I want to hear about how you view the problem and what you see the solutions are. And again, we're going to get it from a diverse set of voices. So it's not just us complaining. I want you to hear from the payers. I want you to hear from the electronic health record companies, how they view the situation.

So I'm very excited about this series. And again, as we get original research in, we are constantly looking for original research that meets this sort of brand. And the way we've defined it from an editorial perspective is if I get an article in, and I think it addresses something that someone in a practice is thinking about on a weekly basis, whether it be the practice administrator or the position lead, or those of us who are out in the trenches, that's an article that we're going to brand as SOCA, that this is one you might want to pay attention to not just for academic interest, but this actually may help you think through what you're dealing on a daily basis. So I'm very, very excited by that.

And again, I think the other thing with this series is that people will find interesting is the use of a physician compare, so you really get a sense of what the oncology force looks like. And let me just kind of give people some of those statistics. So when we look overall, they're a little bit over 12,000 hematologist or hematology oncologists or plain out straight oncologists that are practicing in the United States. They basically put themselves into around 2,200, 2,300 practices around the country. So that's who we are as oncologists.

And one of the issues we didn't have a chance to touch on too much, but has concerned me from the very first time I got involved in this survey, is when you take a look at the mismatch between where the oncologists are and where the patients are, for example, about 7% of our oncologists, 9% of our practices are in zip codes that qualify as rural zip codes. But we know that about 20% of the population lives in rural areas.

So I continue to be concerned about the care for patients in rural areas, especially at consolidation and payer pressures mount. I think it's harder and harder for those small groups to be able to survive in these small areas, and I'm concerned about what that means for the patients and their access to really high quality oncology care. So that's another area that I think we really need to keep an eye on, and not forget. And so within the survey you'll see a really beautifully done map that shows where the practices are, where the survey practices are, and then you can see there are clearly parts of the country that there are blanks.

Yeah, no, that's definitely a major area of concern. As things get constricted by costs, we may need to think of other incentives to try to incentivize practices to continue opening offices close enough for patients to reach. Anything else that we didn't talk about?

The survey actually just went out again, so for those who are listening, talk to your practice administrator. Make sure it didn't go into the junk mail. I think we even give Amazon gift cards out this year to the first few hundred to respond or something along those lines. But really, again, what I emphasize, and I emphasize within our own group, is that this information is critical. This is how we get a pulse on what's really going on out there, and not only is it important to ASCO, but we feed this data to the executive branch.

So for example, on the rural issue, HRSA, who's responsible for a lot of the health shortage areas in the country. We feed them this data so that they know what's going on in the cancer and oncology workforce. And so there are a lot of groups who actually rely on the census, and this is how we build policy, and this is how we sort of think about where our priorities should be.

So we really do listen. This is not just a survey that we can just put out on paper and then forget about it. This really is something that a lot of people pay attention to, so the more data we get back, the richer the data we get back, the more we have things that we can act upon. So please, when you see that survey, please respond to it.

Yeah, and I think it's actually fairly impressive that for really an uncompensated survey that a majority of practices, or at least a majority of the workforce, end up getting included in that. So that represents a lot of work and a lot of recognition of the importance of this. So Dr. Polite, thanks so much for joining me today to talk about this. I know this is always a popular podcast, and I'm sure this one will be no exception.

Well Nathan, again, thank you. And I really want to give a plug out to the work that you do. These podcast series are absolutely fantastic. I encourage everybody out there, you know, I'm probably-- I guess I'm preaching to the podcast choir, but tell your friends out there to subscribe to the JOP podcast, because I think unlike a lot of the other podcasts that tend to go with articles that I think are a little bit more sterile, you just do a wonderful job of making them conversational and getting, I think, to the issues and the questions that people who are reading these articles are asking.

And it's just such a wonderful supplement to, again, I think the rich content within JOP, but really to get the folks who are involved in writing the articles, to give you a little bit behind the scenes and give you a little bit more depth. So thank you for what you do. I know you also are busy and have other things to do, but you do a tremendous job with it. So please tell your friends to go ahead and subscribe to the JOP podcast.

Well thank you for the kind words. We'll pull that out and maybe put it in our marketing for the JOP podcast. And I also want to make sure to thank the listeners out there who joined us for the podcast. You can read the full text of the paper at ASCOpubs.org/journal/jop, published online June 2018, and please keep your eye out over the coming year for all of the SOCA original and invited manuscripts that are going to be coming out. This is Dr. Nate Pennell for the Journal of Oncology Practice signing off.