ACCC Weighs in on Critical Cancer Care Issues:

Since 1974, the Association of Community Cancer Centers (ACCC) has been a leading education and advocacy organization in US oncology. Its membership includes more than 650 cancer programs, 250 physician-group practices, and thousands of nurses, pharmacists, and administrators. Cancer Care & Economics (CC&E) recently spoke with Christian Downs, JD, MHA, executive director of ACCC, about some of today's more challenging cancer care issues.

CC&E: Does the Association of Community Cancer Centers (ACCC) have a solid working relationship with the American Society of Clinical Oncology (ASCO)?

MR. DOWNS: Yes, we've been working with ASCO for the past 5 or 6 years, both on the staff level and on the volunteer or member level. ACCC is an institution-based organization, and a lot of the leaders in ASCO are also members of ACCC.

CC&E: What current regulatory issues are most important to the members of your association?

MR. DOWNS: Our interest in regulatory issues from an advocacy standpoint is really twofold: patient access to therapies and quality cancer care initiatives. Both issues are impacted by the current political environment.

For instance, the Centers for Medicare & Medicaid Services (CMS) proposed a payment reduction for drugs given in the hospital outpatient setting from ASP + 6% to ASP + 5%. Obviously, we were very concerned about how that would affect patient access, since most of the hospital-based programs administer the drugs that CMS considered cutting to ASP +5%.

Consequently, these drugs would wind up being under-water [reimbursement less than cost] at the hospital outpatient departments. In effect, the hospitals would lose money on Medicare beneficiaries, at least from a drug administration standpoint. Naturally, if hospital-based programs operate at a net loss on drugs, they will have to look at ways to cut costs, which might affect access to quality cancer care. We don't want to see that happen. Fortunately, thanks, in part, to our advocacy, CMS stayed with ASP + 6% in its new rule.

CC&E: The use of off-label drugs is imperative in cancer care. Has ACCC taken an active role in this issue?

MR. DOWNS: ACCC actually cut its teeth on the off-label drugs issue. In the late 1980s through the 1990s, ACCC was one of the groups primarily responsible for getting off-label laws passed on the state level. In other words, if a health insurer was regulated by the state, we went into that state to ensure that laws were passed to cover the off-label use of drugs in cancer. We got off-label coverage passed in 39 states, which was very exciting on a state level.

On the federal level, we've been working with groups like ASCO, looking at the current compendia process to see how we can improve access to off-label use of drugs in the Medicare system.

Off-label drugs are going to be a critical issue in the next 5 years, and we could see activity, both by private insurers and public insurers, to potentially reduce access. I want to make sure that whatever is done is evidence-based and does not have a negative impact on cancer care.

CC&E: Is maximizing efficiency in the delivery of care an important issue with ACCC?

MR. DOWNS: Yes, it is. We have launched several web-based education programs about practice efficiency in the physician office site, and this goes from the most basic skill set to some pretty advanced stuff. One of the most basic programs is, "Are you coding correctly?" Evaluation and management documentation is a big part of getting properly paid for the care oncologists provide, and proper coding in this area can make or break an oncology practice.

Put simply, the clarion call in the next 5 years for office-based practices is "efficiency with a capital E." Just when you think you are efficient, you need to be more efficient in order to keep pace with the ever-changing billing and coding structures that have become part of delivering cancer care.

CC&E: To that end, are electronic medical systems an important agenda for oncology?

MR. DOWNS: Absolutely. We've done several meetings focused on the benefits of electronic medical records. I think e-records are a key component to enhancing overall cost-efficiency. However, the challenges with adopting electronic medical records are the initial costs and implementation and the temporary disruption of workflow. On paper, e-records look very good, but quantifying improved efficiencies and outcomes in the complex world of oncology is difficult. So there are some hurdles to overcome before this technology is fully embraced by the oncology community. There's also the natural reluctance humans have to change. But we'll get there.

CC&E: What's your take on the Pay-for-Performance (P4P) initiative?

MR. DOWNS: Pay-for-performance is a fascinating concept, but I think that connecting real efficiencies to the concept, at least from a cancer standpoint, is pretty far down the road. Although P4P has the potential to improve quality in some instances, cancer care reimbursement and cancer quality measures are so complex that there might be better medical venues to first test the value of any initiative that rewards providers for recommended care.

In other words, in cancer care, if the pay doesn't change enough to affect the performance, and the performance doesn't change enough to affect pay, then the P4P initiative will have relatively limited impact on the delivery of cost-effective quality care.

Having said that, I think the oncology community should always look at structures that create an incentive to deliver cost-effective quality care. It's in our own best interest to be open-minded.

CC&E: Any closing thoughts on the challenging times ahead?

MR. DOWNS: There is no question that America's aging population poses a challenge to our limited cancer care resources. That is a fiscal reality that must be dealt with. However, we're making great strides in detection and treatment. The growing millions of cancer survivors in America attest to that.

I think the real challenge is going to be how to avoid a situation in which care and cost intersect in the clinical decision-making process. That's an age-old dilemma in oncology, which will be further tested by the growing number of very expensive biologics coming out of the laboratory.

But if you put a Wall Street analogy on the forecast, I'm bullish on cancer care. Outcomes and survival have continued to improve, and we at ACCC will keep on working to ensure that our nation's providers have the tools and resources they need to provide quality cancer care to their patients.