ASCO Fights Perception That Independents Get Short Shrift

Daniel F. Hayes, MD

ASCO is working hard to overcome a perception that it has not been truly representative of smaller, independent oncology practices throughout the United States, said Daniel F. Hayes, MD, president of the ASCO, which is the largest association of working oncologists in the country.

Hayes, who sat down with OncLive at the midpoint of his 1-year term as president, said ASCO is increasingly reaching out to independent oncology practices, paying closer attention to their needs, and supplying them with tools and services to manage the difficult transition to value. Joining him for the interview was Stephen S. Grubbs, MD, vice president of Clinical Affairs for ASCO. Grubbs is leading many of the practice education and quality improvement initiatives at the organization.

OncLive: How might Thomas Price, MD, recently appointed to the position of US Secretary of Health and Human Services, influence healthcare policy in Washington, DC?

Do you expect a change in the focus of CMS’ reform efforts, particularly with respect to implementation of the Medicare Access and CHIP Reauthorization Act (MACRA)?

What’s the role of the smaller, independent oncology practice in this changing landscape?

The 2 doctors discussed wide-ranging topics that included the change of administrations in Washington, DC, and what that may mean for the direction and consistency of the reform program at CMS. They also discussed the growing influence and power of pharmacy benefit managers (PBMs) over the supply of oral oncolytics and the effect of this control over independent practices. In addition, they covered physician recruitment difficulties, medical school training, the use of advanced practice providers (APPs), and the very future of independent oncology practices in a landscape of increasing consolidation and economic challenge.Hayes: We congratulate Dr Price and look forward to his tenure. He has a lot on his plate right now, including what to do to repeal and replace the Affordable Care Act. At ASCO, we have a variety of things we’re concerned about. Our main concern is that patients who are at risk or have cancer or are recovering from it have access to care without preconditions and that they have access to clinical trials. We are also confident that Dr Price will continue to be an advocate for increased funding at the National Institutes of Health and the National Cancer Institute. He was a major supporter of the 21st Century Cures Act.Hayes: I don’t think any of us know. ASCO’s not going to change its principles. We are all about taking better care of our patients, so our principles are that patients should continue to have access to affordable and high-quality care. We’ve been supportive and have worked with CMS as they’ve begun to develop quality and value-based reimbursement as opposed to fee-for-service. MACRA is not perfect, but to their credit, CMS has worked with us and has accepted many of our recommendations. Ultimately we will have something that physicians and oncologists embrace.Hayes: Almost 90% of patients who are treated for cancer in this country are treated by community oncologists. That definition is getting fuzzy, as we have more and more partnerships between what used to be true private practices and true academic practices. They’re beginning to come together and merge. What we really care about is whether patients have access to high-quality care, no matter where it is. And there are practices in this county that are not being encompassed by academic centers that will remain independent practices, and a third of our patients are in those. That’s a complex environment.

Has ASCO managed to convince independent practices that it’s batting on their team?

The wave of practice mergers and acquisitions continued in 2016. Is there truly a place for small, independent practices in the future?

Independents contend the 340B Drug Pricing Program gives larger institutions an unfair advantage. Where does ASCO stand on this?

We need to be sure that the Department of Health and Human Services and CMS continue policies that help physicians in broad geographic areas with lower populations to remain engaged and to take care of patients. In northern New England and the Midwest, for example, you’ve got people spread over many, many miles. If 1 practice goes out of business, suddenly patients find themselves 80 miles from an oncologist rather than 15 miles from an oncologist. We need to be sure that doesn’t happen, and ASCO is committed to helping doctors in those situations remain where they are and remain solvent and remain satisfied with their practices.Hayes: My own feeling before I became president of ASCO was there was concern among many oncologists who were in community practice that ASCO was detached from a lot of their problems and concerns. I’m not entirely sure that was fair, but the perception was out there. With the involvement of Dr Grubbs and his department, Clinical Affairs, I think we’ve taken a major step toward resolving those issues and, hopefully, diminishing that perception. Steve really has led some of the practice improvement efforts at ASCO. Belonging to ASCO is more than having a card in your pocket. It really is a way for folks to relatively painlessly embrace the changes that are coming, which I believe will be good for our patients.Hayes: We think they’re pretty necessary, even more so where there are large geographic distances. I practice in Ann Arbor, Michigan, at the University of Michigan—and Michigan is huge. There are people in Michigan who live farther from me that people in Philadelphia. Those patients can’t all get to Ann Arbor, Michigan, and have Dan Hayes take care of them. We are trying to reach out and provide support for practices through the University of Michigan. We at ASCO are dedicated to helping these practices figure out what the changes are, what the gaps in their practices are relative to the changes in payment policy, and helping them fix those. If I’m in private practice by myself, I don’t have the wherewithal to understand all of this and get it together on my own. ASCO’s there to do that for them. Dr Grubbs’s department is basically making those things available, so you don’t have to be a big practice. You just have to be a good one, and I think that’s a good mantra.Hayes: We’re very much in favor of the original purpose of 340B, which was to provide patients with care in geographic areas where they were underserved, and that’s a good intent. Obviously, 340B as it was intended has been altered. ASCO has a policy statement out that it be reviewed, and we’d be happy to be part of any review that goes on, so that patients who live in areas that are underserved aren’t underserved, and so that patients have access to high-quality care.

Grubbs: I believe 340B should be applied to any situation where it’ll improve access for underserved communities, and that doesn’t necessarily need to be a university-type hospital. I think anybody who’s taking care of the underserved should have the advantages of 340B to help them have access to those communities.

PBMs have worried independents, especially last year with CVS Caremark’s aborted attempt to restrict access to Medicare Part D oral oncolytic distribution. What is ASCO’s perspective on this situation?

Grubbs: We’re aware of PBMs. We have a state affiliate council that represents all of our state and regional oncology medical societies, and this is an issue that has been brought to our attention. We’re still looking into some of the issues that are happening there. We understand the duress that the independent practices are under and some of the advantages that they have in doing their own oral dispensing. We haven’t made a statement about that, but that certainly is on our agenda of ongoing review with our state affiliates.

How is it possible to overcome the shortage of oncologists that ASCO has identified?

Hayes: We’ve really made a big effort to embrace the state affiliate councils (ASCO membership)—by bringing them to ASCO’s headquarters so that we can hear what the problems are and help address them. We now have the chair of the state affiliate council attending our quarterly board meetings so that we can hear about major concerns before they blow up. This is one of the concerns that we’ve discussed. We certainly do not want patients unable to get medications that could be life-saving for them. We’re going to be a player in this and we’re going to make sure that that doesn’t happen.Hayes: My son, who just graduated from medical school, got no more than 2 to 3 lectures on oncology—total—before he went into his clinical years. And when he went into his clinical years, he was placed in the wards, and all he saw were patients who were sick and dying of cancer. He didn’t understand what we do and why we do it.

We need to get medical students and trainees into the outpatient clinic. We need to show them why we’re excited about oncology, why immunotherapy is such an exciting approach—and precision medicine and personalized medicine. ASCO is trying to do that. We have reached into the medical schools; we have supported cancer interest groups. I’m part of one here where we just have faculty talking about what we do and why we do it and how to make a career out of this. We’re really making an effort to get these kids to understand that while cardiology is fun and cool, oncology is a wonderful profession, that we really make a big difference, that we affect people’s lives favorably, and that the science is fascinating.

Some say that the growing workload, which includes a predominant amount of time not seeing patients, is a turnoff for prospective oncologists.

Hayes: ASCO has taken some efforts to look at workforce issues down the road, and physician burnout. One thing we’re very supportive of is working with folks who don’t necessarily have MD or DO after their name—nurse practitioners and physician’s assistants, for example. We’re starting to work with those groups. The physicians are doing things that they are trained to do, and APPs are doing what they’re supposed to do. The doctor is not working on something that somebody lower-priced could do just as well.

I’m a better doctor because I have a nurse practitioner who knows how to do things I don’t know how to do. In fact, we’ve done such a good job with APPs in our institution that our patients have become comfortable with having them provide care. They want to see medical practitioners and physician assistants, and I can tell you that wasn’t necessarily the case 15 years ago, so this is the kind of thing we can do to help lessen the burden on physicians and ease the labor shortage.