The Politics & Economics of Cancer Care: 2003

Making Disease Treatment
Standardization Work in
Community Practice
Jim Koeller, M.S.
University of Texas at Austin & the
Health Science Center, San Antonio
Expectations For 2007?
• The bottom line:
– Things will get worse (revenues will tighten even
more), we are not close to the bottom yet.
– Not everyone will survive or probably need to
survive (this is somewhat Darwinian ~ the strong
will survive)
– You do not have to change, but their Will Be
consequences for your lack of action!
– You can control much of your own destiny, or
much of it will controlled for you.
– Those who survive will be leaner, stronger, more
efficient and just better! (look at the dialysis
Expectations For 2007?
• Core reimbursement shifts continue to change the
oncology business model (drug vs. service
– CMS practice expense (some decreases)
– Imaging procedure cuts (technical component to
be paid at OPP’s rate)
– Pt shifting to increase?
• ASP remains (GAO, MedPac, OIG all think it
– Stabilizing quarterly rate fluctuations
– Continuing issues: 2 quarter fee increase lag
and exclusion of the prompt-pay discount
Expectations For 2007?
• Commercial payers
– Continue to switch to ASP-based payment (BCBS)
– Continued push for specialty pharmacy use
• Will CAP survive?
– 300+ physicians (22 oncologists)
• Demonstration project discontinuation
– Was considered a precursor to P4P initiatives
• Practices to continue work on  efficiency, controlling
costs and expanding revenue sources
• More emphasis on quality, P4P, transparency
– Making costs and MD-to-MD quality comparisons
available to all
• Most clinics have done ‘OK’ in 2006…
The New Face of Oncology
• Oncology is being moved in the direction of demonstrating
quality of care, P4P, and transparency..
– Transparency is becoming the new theme
– ie., making cost and physician-to-physician quality
comparisons available
» Data will become KING (which makes EMR a
» Note: just having the data will not be enough!
» Everyone cannot get everything ~ demonstrating that
you can control the use of resources will be critical
– You will need to format your data to tell this story
» Will need to be able to demonstrate a control of
resources and still able to provide quality patient care
– Benchmarking will become critical
Pay For Performance - P4P
(ie., Quality Measures)
• Most of this to date has been hospital-based
– Probably over 120 different P4P programs now
– Most of these are medicare/medicaid (10+ different
demonstration initiatives)
– Reporting Hospital Quality Data for Annual Payment
Update (RHQDAPU), has 21 quality measures that if
not reported result in a 2% payment decrease
– Premier Hospital Quality Initiative involved 272
hospitals and 34 quality indicators for 5 clinical
conditions providing a 2% bonus for the top stratum
• Community-Based
– 3-year CMS demonstration project with 10 large (200+
docs). The goal for now is to save money
Pay For Performance - P4P
(ie., Quality Measures)
• Quality care measuring in oncology
– CMS’s 2005/2006 demonstration projects dealt with side effects
and adherence to guidelines
– Most agree that true quality measures should address clinical
– Cancer pt outcomes depend on P.S, type & grade of tumor,
metastases, treatment type and generally are measured only over
a longer period of time
– This will require documentation and extensive data capture - EMR
– Until that time we expect CMS to focus on:
» Utilization and cost management
» Narrowly focused effectiveness of treatment
» Pt. safety
» Adverse events
– To report on such measures means clinics will need to define
treatment plans in terms of standardized regimens
What are Community Practices
Doing Now?
• Benchmarking can take on many identities
• For all in tense and purposes, practice benchmarking is in its
• Manages have benchmarked macro practice performance
measures for some time
– Patient visits
– New patients
– Patients treated
– Charge and revenue information (by category)
• Some electronic drug boxes are providing drug use
• I am unaware of the existence of a sophisticated clinical
database (this isn’t to say the data doesn’t exist in some cases)
– Presenting clinical data by disease type which would
include demographics, treatment, toxicity and specific end-
So, what major changes
to how you are
‘practicing’ oncology do
you make?
Where do you start…
Practice Changes
• The community practice’s core business will become
the infusion center ~ will need to put more emphasis
on it...
• Work efficiency, overhead, , personnel issues,
evaluating services provided, looking at new services
to provide (diversifying revenue streams)
• Documenting quality of care (transparency)
– EMR is necessary
– Standardization of chemo regimens will ensure
consistent drug use
– Standardizing treatment strategies for common
cancers (ensures consistent patterns of drug use)
– Must be able to demonstrate control of resources
with a ‘positive’ outcome
Understanding the Basis of Your
In Community & Hospital
Oncology Practice,
chemotherapy infusion
is becoming the oncologists
Understanding the Basis of Your
• Business 101
– What is the “cost” of your unit of business
» Your procedure is the chemotherapy infusion
– What revenue is generated by that unit of
» Most businesses are allowed to set their price
to make a margin (which covers costs and
provides a profit)
» For oncology, your revenue amount is set for
Understanding the Basis of Your
• Understand the cost of your procedure ~
– Cost per hour of infusion chair time
» Practice overhead (fixed)
» Nursing time
» Support personnel (LVN,MA)
» Chemotherapy preparation
– Typical chair per hour cost ~ $68 - $300+
A Few Suggested Basic Rules
Put more emphasis on your infusion center
A new pt. Should not be treated on the 1st-day visit
Nurses should not education in the infusion chair
75% of pts. need not be treated between 10:30am &
Infusion & Injections should be two separate processes
Nurses should not mix chemotherapy (technicians)
Pts. should not spend 2+ hrs. in the clinic to receive a
10 sec. injection
Nurses need to control the primary care nursing they
perform at the infusion chair
Lost drug charges need to stop
When possible, have an ‘expert’ manage your
Treatment Variability in Practice
• If you provide a single patients case to 10
oncologists, how many different treatment plans
would be suggested? (at least 10 probably)
• Physicians typically treat by an N=1.
– Physicians do not process data by groups of
– Do physicians really know what happens to a
cohort of patients they treat?
» What happened to the last 50 metastatic
breast cancer ladies you treated as a group?
• Physicians generally do not have organized clinical
databases on treated cohorts of patients
Standardized Regimen Orders
• Create standardized regimen “recipes” (including
– Helps control nurse administration variation
» Which has been measured to exceed 200%
– Sets a standard for the specific administration
method and time for each agent
» All AC regimens in your practice should
basically be given the same, and so on…
» The top 40 regimens make up 80% of what’s
Chemotherapy Orde r Form
[Carboplat in (AUC 5-6) + Gemcitabine 750 - 1000 mg/m2 Day 1 & 8) Q3wk]
(One cycle)
Date:_____________ P t . Name: _____________________ Dr. _________________
Ht (in):
Wt (lbs):
Cr =
Est. CrCl =______ Dose =
mg=____ • (
+ 25)
target AUC
DRUG ORDERS: (W e ek One) (total infusion t ime= 1 hr. 30 min.)
Hydrat ion – 1000ml NS – to infuse at 175ml/hr
Decadron 20 mg in 50ml NS to infuse over 20 min.
Aloxi 250 mcg, give IV push over 1 min.
Carboplat in (AUC-___) =______mg in 250ml NS to infuse over 30 min.
Gemcitabine (____ mg/m2)= ____ mg in 250ml NS to infuse over 30 min.
W e ek Two – Date:_________ (t ot al infusion t ime= 1 hr. 15 min.)
Hydrat ion – 1000ml NS – infuse at 175ml/hr
Decadron 10 mg in 50ml NS to infuse over 20 min.
Aloxi 250 mcg, give IV push over 1 min.
Gemcitabine (_____mg/m2)=_____mg in 250ml NS to infuse over 30 min.
If ANC > 1000 & P lt. > 100,000 ~ give full dose
If ANC 500 – 999 & P lt. 50 – 99.000 ~ give 75% dose
If ANC 500 – 999 & P lt. 30 – 49,000 ~ give 50% dose
Neulasta 6mg SC inj. (for full-dose tx with ANC 500 – 999) Date: ____
Dr. Signature:
The Hypothesis Is …
If you provide the “right”
information on a specific cohort
of patients including their
treatment to those who provide
the care, they will make the
appropriate treatment decisions.
Koeller - 1991
Making the Right Care Decisions
• Treatments for the primary diseases of breast,
lung and colon cancer have become increasingly
– Newer active agents
» Including targeted therapy
– More lines of therapy
– More options for each line of therapy
– Many more supportive care options
– The need to take into account patient & toxicity
issues (including QOL)
Why is Controlling Disease
Treatment So Important?
• Current community practice has shown a variation in
treatment approach of over 400% (resources utilized) for
advanced Lung, Breast and Colon cancer
– Variation causes significant treatment inefficiencies
• Infusion and injection numbers and frequencies are
established by individual physician practice patterns
– By being more consistent with disease treatment
approaches, a clinic can have a better handle and
control over the number of infusions & injections
– What diseases do you manage: Advanced NSCLC,
Breast, Colon, Ovarian, & Prostate cancer (roughly
65+% of a clinics pts).
Koeller, et al. Data on file, 2006.

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