2013 Cancer Center Business Summit
Perspective
Options for Oncologists to Preserve Independent Private Practice By Michael L. Blau, Esq
Background Market and government reforms are transforming the health care landscape. These changes are being driven by the economic— and some would say social and moral—imperative to reduce the unsustainable rate of growth of health care spending in this country. Those costs make the United States the most expensive health care system in the world; drain federal and state coffers and crowd out other social priorities; strain household budgets and cause an unacceptable rate of medical bankruptcies; and make health care unaffordable or inaccessible for far too many Americans. Oncology is responsible for its fair share of these increasing health care costs. It accounts for up to 10% of all health care expenditures by some estimates.1 And oncology costs are increasing faster than many other health care components because of expensive new drugs1 like Provenge (Dendreon, Seattle, WA), Zytiga (Janssen Biotech, Horsham, PA), and Xtandi (Astellas, Northbrook, IL; Medivation, San Francisco, CA); expensive new molecular diagnostics; and expensive new robotic technologies and therapeutic technologies like proton beam therapy. It has gotten to the point that some patients are as afraid of the out-of-pocket cost of their cancer care as they are of their cancer. Virtually everyone agrees that it is time to seriously reexamine our fragmented, expensive health care system and to innovate sustainable ways to cure its ills. The private market is moving inexorably in this direction through new value-based purchasing and alternative payment arrangements (like pay for performance [P4P], shared savings, bundled payment, episode of care, and global capitation arrangements); through reorganization of providers into accountable care organizations (ACOs), medical homes, and other clinically integrated care organizations that span the full continuum of care and are focused on population health management (PHM); through new health insurance product designs that involve higher patient copays for more expensive care options; through limited, tiered, and exclusive provider networks; through redesign of care delivery processes; and through practice acquisitions and industry consolidation to achieve economies of scale. The offices of health care executives today are replete with talk of bold initiatives to reimagine, redesign, and rebuild our system of so-called sick care, which is focused on acute and episodic care, into the PHM system of the future, which is to be focused on proactively keeping patients healthy. The current pace and extent of planning for the change to PHM and valuebased care is unprecedented, and there is a growing sense of Copyright © 2014 by American Society of Clinical Oncology
urgency—the stakes are high, resources are constrained, and the right investments need to be made before opportunities disappear or are claimed by others. The prospect of change of this magnitude can be exhilarating. It can drive innovation and create new opportunities for community oncology. But it can also be unsettling, breed uncertainty, and create a lot of anxiety. That is what many community-based oncologists report feeling today. They are concerned about reimbursement reductions for chemotherapy, radiation therapy, and imaging; about reduction in demand for elective services as a result of increased patient copays; about being excluded from payer contracting networks because of the relatively high cost of oncology care; about losing referral sources as primary care physicians and other specialists align with specific networks; about the pressure to give up their practice autonomy and become employees of hospitals, strong multispecialty groups, or health systems; about the shift to use of midlevel providers practicing at the top of their license; about whether payers will pay for the transformation to value-based care and personalized medicine or for new state-of-the-art drugs and technologies; and about the projected reduction in need for oncology care under stringent managed care systems that incentivize lower specialist usage rates. In the face of these changes and challenges, communitybased oncologists want to know what strategic options they have to remain independent during the transition to PHM arrangements and to succeed in the more integrated health systems of the future.
Some Preliminary Considerations This article is intended to help oncologists make informed choices about their potential pathway(s) to success in their local markets that preserve some modicum of independent private practice. It addresses ways that oncologists can affiliate with other physicians and medical groups to achieve this end. It does not address affiliations with other parties such as hospitals; health systems; or practice management, health information technology, or private equity/venture capital companies, which may also assist private practice oncologists to remain independent. It is almost a cliche´ to say that all health care is local and that what works in one market may not work in another. There is no one-size-fits-all solution to preserving independent private practice for oncologists. Any successful strategy must respond to the unique stakeholders and competitive dynamics in the locality. That said, it is possible to discern some success factors
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Foley & Lardner, Boston, MA
Michael L. Blau
Critical mass is necessary, but not sufficient, for private practice to continue to be a viable option for oncologists in many competitive markets. To improve your group’s negotiating position, whether as a vendor to other provider organizations or in relation to payers, it may help significantly if your oncology group (or network) is the dominant quality provider of oncology services in your market. If it is, then your group or network may be relatively indispensable to local hospitals, health systems, and payers that are looking for a broad and deep enough bench of oncology providers to meet patient care needs in a conveniently accessible, timely, and high-quality manner. Critical mass also provides some protection against destructive competition, because it makes it more difficult for even a large health system to justify the effort, expense, and risk to try to replicate your capacity. Duplicating your capacity could take considerable time, involve substantial investment and an uncertain outcome, and may ultimately not be successful. The more rational result may be for the health system to do business with your group or network on reasonable (or even premium) terms, whether on a transitional or long-term basis. The pathway to future success is therefore likely to be predicated on your group or network having a critical mass of the quality oncologists practicing in your local or regional market. In some markets, a dominant hospital, health system, or multispecialty group may be too far ahead of you to permit you to catch up. If the quality oncologists or groups in your market have already made contractual commitments that preclude their ability to join you in a larger oncology enterprise, you may ultimately have no choice but to play ball with the dominant system, in some way, and bargain as best you can for your fair share of their business and health care dollars. Where your oncology group or network has the opportunity to assemble and grow to sufficient scale on a regional or statewide basis to gain market significance, the options for doing so are discussed in this article. Even if you can overcome the considerable hurdles to build critical mass in your market, size alone is no longer sufficient to ensure your success. Many payers are offering only general inflation rate increases (ie, currently 2% to 3%) for physician services and are reducing payments for ancillary services. Payers are typically no longer offering to increase payments by the rate of health care cost inflation (which historically has been closer to 5.5%). Payers are generally only willing to offer more than an inflation adjustment if oncology providers can demonstrate 88
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that they can provide a correspondingly better cancer care value proposition. Under new alternative payment contracts, providers can receive additional amounts in the form of bonuses for measurably improving quality and outcomes; shared savings produced by reducing cost and utilization; and/or surpluses generated by budget-based payment bundles, episodes-of-care payments, or capitation arrangements. Negotiating for some combination of general inflation increases and value-based payments (by demonstrating quality and cost-effectiveness) will probably be the best way in the foreseeable future for independent oncologists to position themselves to optimize their bottom-line financial results. The emerging message from the payer community is that oncologists are unlikely to do as well financially in the future without accepting some risk for the quality and cost of care they provide, and doing the real work necessary to redesign care processes and create new value in oncology care. In this regard, community oncology has the opportunity to develop new value by curbing variability and overuse of cancer drugs and therapies; changing physician incentives to select the most cost-effective treatments rather than the most profitable ones; proactively monitoring patients for pain and drug adverse events to avoid avoidable emergency department visits and hospital admissions; and eliminating futile end-of life services. If community oncology groups do these things well, they should have the opportunity to share in the resulting cost savings. So oncology providers who want to remain independent should be “care-ready”—they should be prepared to be engaged, active participants in designing the care protocols, pathways, and care management and coordination processes that will enable the delivery of more efficient and effective cancer care in the health care and oncology care systems of the future. Community oncologists also need to become “risk-ready” and “deal-ready.“ That is, they will probably need to either develop, or affiliate with an organization that has developed, the infrastructure to accept and manage increasing financial risk for the quality and cost of oncology care they provide. Such infrastructure includes the human and technological resources to do such things as track, measure, and report on pathway compliance; manage use of ancillaries and drugs; stratify patients by susceptibility to cost-saving interventions; proactively monitor patients between office visits; support home-based care; provide after-hours care management or navigation; and support endof-life planning and palliative care. Being risk-ready may also involve negotiating risk pool payment arrangements with appropriate withholding, risk-sharing, and surplus-sharing provisions as well as insolvency protections (eg, stop-loss insurance, reinsurance, financial reserves). Being deal-ready requires that the oncology group or network have the executive leadership and skills to identify and execute on strategic transactional opportunities for growth. This may entail recruiting and onboarding oncologists; merging or consolidating with other oncology practices; negotiating with payers, ACOs, primary care medical homes, and employers; accessing sources of capital; and affiliating with hospitals and other health system components.
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that may help guide oncology groups in considering their strategic alternatives. Those success factors include: • obtaining critical mass, • developing a new value proposition, • being in network with as many systems as possible to secure an adequate referral base, • being “care-ready,” • becoming “risk-ready,” • being “deal-ready,” and • getting the timing right for transitioning from fee-for-service payments to risk-based payment arrangements.
Options to Preserve Independent Practice
• economies of scale (eg, insurance, employee benefits, staffing, operations); • improved ability to develop and support ancillary revenue enhancements (eg, imaging, clinical trials, ambulatory surgery); • better resources for strategic and business planning; • central information technology platform and clinical integration; • increased capacity to accept risk for the quality and cost of services and to manage care and use; • greater array of specialized programs and services (eg, medical, radiation, breast, colon, and lung specialists); • quality improvement through peer interaction; and • improved quality of life (eg, more coverage/less call). There are also distinct legal advantages to consolidating separate oncology practices into a single, fully integrated supergroup: • The ability of participating oncologists to jointly price, or collectively bargain, with payers and vendors, without engaging in illegal price fixing in violation of federal and state antitrust laws. • The ability of participating oncologists to refer to one another while sharing an economic relationship and without violating federal and state Anti-Kickback Statutes. • The ability to share ancillary revenue without violating the Stark Law.
Options to Preserve Independent Private Practice Oncology supergroups. One of the factors for success in remaining independent is critical mass in a market. One way to achieve such critical mass is to form an oncology supergroup in a region or state. An oncology supergroup is a fully integrated organization that combines independent oncologists and oncology groups into a single group practice entity that practices under a single tax identification number. To be an oncology supergroup, the organization should have, or plan to include, a sufficient number of quality medical, radiation, specialty, and/or surgical oncologists at a sufficient number of key needed locations to be vital, if not indispensable, to any payer whose members need access to high-quality, affordable oncology care across the region or state. Examples of oncology supergroups include Texas Oncology (Dallas, TX), Florida Oncology Specialists (Fort Myers, FL), and Regional Cancer Care Associates (Hackensack, NJ). There are several structural options for organizing an Oncology supergroup. Those options include a traditional medical group, with standardized operations and a single compensation pool; a holding company that becomes the parent of existing practices with all of the existing physician-stockholders becoming owners and employees of the holding company; or a group practice without walls, with each oncology group operating as a separate division and profit/loss center of a single practice entity. Each structure has different business and legal implications (that are beyond the scope of this article to review). What all of these supergroup arrangements have in common are certain core potential business advantages. They include: • improved market position for recruitment, growth, and future success; • enhanced bargaining power in relation to payers and vendors; • improved access to capital for technology and growth; Copyright © 2014 by American Society of Clinical Oncology
There are, however, antitrust constraints on how large a supergroup can be. Under applicable Federal Trade Commission Safety Zones and Guidances,2 an oncology supergroup can, with impunity, include up to 20% of the oncologists in the relevant geographic market on an exclusive basis (ie, the oncologists can only contract with payers through the supergroup and not on their own or through a competing physician organization) and up to 30% on a nonexclusive basis; a Medicarecertified ACO can contract on a nonexclusive basis with a supergroup that has up to 50% of oncologists. The relevant geographic market for antitrust purposes is generally defined as the area (defined by zip codes) from which the constituent oncology groups draw either 75% or 90% of their patients for such services. It is possible, in the future, that the antitrust enforcement agencies may analyze the geographic market for oncology services more narrowly or may evaluate the service markets for oncology subspecialty services separately (although they have not historically done so). At the bottom line, on the basis of antitrust enforcement agency precedents, if the market for oncology services is relatively fragmented and unconcentrated, a supergroup can probably include up to 40% to 50% of the oncologists in the relevant service market (ie, measured by outpatient ambulatory oncology services and/or inpatient oncology services) and in the relevant geographic market (ie, the 75% or 90% patient draw area) without raising any material antirust concern. This is more than adequate for the supergroup to have an opportunity to succeed in its business objectives, particularly if it is composed of high-quality physicians.
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Getting the timing right for the transition from fee-forservice to value- or risk-based payment arrangements is also a key to success in maintaining a viable private practice. If your oncology group gets too far ahead of the market by aggressively seeking early participation in alternative payment arrangements, you may end up leaving considerable fee-for-service dollars on the table and take a significant hit in physician compensation. Conversely, if your group is too far behind the market in moving to alternative payment and delivery arrangements, you may lose risk-based opportunities to competitors and may not have those opportunities in the future. Once too far behind the market, your group may never be able to catch up. To complicate matters further, the timing of the transition to value and risk-based arrangements may be dictated by specific local market conditions and state regulation. For example, providers in major urban/suburban parts of states like Massachusetts and California may be years ahead of providers in neighboring regions or states in transitioning to alternative payment and delivery arrangements.
Michael L. Blau
There can also be numerous obstacles to consolidating oncology groups into a supergroup:
Of these, different cultures and lack of trust may be the two greatest obstacles that are the most difficult to overcome. Tremendous strides in that direction can be made through an inclusive, engaged, and respectful planning process in collaboratively designing and developing the supergroup. That planning process should address all material structural, governance, operational, technological, and financial design features of the supergroup. Such an inclusive and comprehensive planning process is a key to getting sufficient buy-in for oncology groups to commit to forming the supergroup. Oncology networks. If the obstacles to forming an oncology supergroup prove insurmountable, it may be easier to obtain critical mass by forming a single-specialty contracting network composed of independent oncologists and oncology groups. To be successful, such a network, like a supergroup, would need to include a sufficient number of quality oncologists at a sufficient number of key locations to be vital, if not indispensable, to any payer or health system whose patients need access to high-quality cancer care in their markets. Such a network could be a carve-in (or carve-out) network for any health system, physician-hospital organization (PHO), ACO, or patient-centered medical home (PCMH). Examples of such oncology networks include Cancer Clinics of Excellence and Oncology Resource Networks of America. One obstacle to forming an oncology network is the extent to which oncologists are already under contractual constraints that may prohibit their joining the network. If the oncology group is already a member of a multispecialty independent practice association (IPA), PHO, or ACO, the group may have already contracted away its ability to join another network, at least until it can terminate its existing contract. Oncology groups also need to assess whether they will lose referral sources if they leave their current IPA, PHO, or ACO to join an oncology network. This concern may resolve on its own over time if the oncology network is successful in becoming an adjunct or carve-in to multiple contracting organizations, including those with which the oncology group currently participates. To be able to bargain collectively with payers under such network arrangements, the participating oncology groups 90
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• Different cultures. • Different information technology platforms (especially if the group has undergone a recent information technology conversion). • Different billing arrangements. • Different debt profiles. • Different payment contracts/rates. • Different practice values. • Different use of midlevel providers. • Different staff salary and benefit structures. • Different buy/sell arrangements. • Different quality and use profiles. • Lack of trust.
would need to be sufficiently financially and/or clinically integrated for antitrust purposes.2 Financial integration consists of sharing substantial financial risk.2 Examples include capitation agreements, withhold pools, global fee, certain payment bundles, episodes of care, case rates, and certain bonus arrangements. A key to a substantial financial risk arrangement is that there must be shared risk—that is, a substantial portion of the oncologist’s payment must be based on the aggregate performance of all physicians in the network (or risk pool) and not just based on individual quality or use performance. Programs, like the Medicare Physician Quality Reporting Initiative program provide bonuses for individual physician quality performance and therefore do not involve substantial shared financial risk and would not qualify the network as a financially integrated network for single-signature contracting. Nor do indemnity, fee-for-service, or preferred provider organization payment arrangements involve shared financial risk. In contrast, clinical integration focuses on the quality control, information systems, and protocols established by the physician network that lead to increased quality, efficiency, and modification of use and practice patterns.2 The use of clinical practice guidelines help qualify a network as clinically integrated. This is because use of clinical pathways reflects an effort to have all network physicians follow best clinical practice, reduce variation in care, and standardize quality care to the extent feasible. Coupled with utilization review targeted at compliance, use of clinical guidelines can demonstrate that the network is coordinating care to achieve higher quality and/or lower costs, thereby distinguishing itself by delivering better (and procompetitive) value-based care to patients. The Department of Justice and the Federal Trade Commission define clinical integration as “integration [that] can be evidenced by the network implementing an active and ongoing program to evaluate and modify practice patterns by the network’s physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality. This program may include: (1) establishing mechanisms to monitor and control utilization of health care services that are designed to control costs and assure quality of care; (2) selectively choosing network physicians who are likely to further these efficiency objectives; and (3) the significant investment of capital, both monetary and human, in the necessary infrastructure and capability to realize the claimed efficiencies.”2(p91) To achieve sufficient clinical integration, the oncology network must commit to a serious effort to establish goals relating to the quality and use of oncology services; to monitor participants’ performance concerning these goals; and to take concrete steps, where necessary, to modify participants’ actual practices. To do so, the network will need to make significant investments in information systems, data analysis and reporting capabilities, and the human and administrative resources necessary to implement these programs. The principal downside to an oncology network is that if it does not achieve substantial financial and/or clinical integration, then it can be easily bypassed by payers. Absent sufficient
Options to Preserve Independent Practice
integration, the network would not be able to contract on a single-signature basis and would not be able to bind its participating oncologists to contracts. As such, payers could elect not to recognize the network as a legitimate bargaining agent and could insist on contracting separately with each participating oncology group. By this means, payers could divide and conquer the network.
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Oncology ACO. Oncologists can join a Medicare ACO or may be able to form their own oncology-only commercial ACO. Oncologists can sign up to participate in Medicare ACOs that participate in the Medicare Shared Savings Program (MSSP). These are principally primary care– oriented organizations, and oncologists would need to bargain hard for meaningful governance rights and for a fair allocation of cost savings, performance-based bonus payments, and risk pool surpluses. Generally, oncologists will not be able to form an oncologyonly Medicare-certified ACO for MSSP purposes. That is because Medicare fee-for-service patients are assigned to a Medicare ACO based on the primary care physician from whom they receive most of their primary care services. Patients are not assigned to an MSSP-participating ACO based on their oncologist or other specialist physician unless the patient does not have a primary care physician and receives most of the patient’s primary care services from an oncologist or specialist. That would rarely be the case. Accordingly, as a practical matter, there cannot be an oncology-only ACO for MSSP purposes. Enterprising oncologists, however, may be able to design and implement an oncology-only ACO to do business with commercial insurers. Such a commercial oncology ACO would include a health system partner (and potentially other cancer care continuum providers) and an interested commercial insurer. The commercial insurer would pay for the value produced by the oncology ACO in reducing costs and improving quality (such as described in the oncology medical home model), while the health system partner would work with the oncologists on transitions of care and in redesigning value-based inpatient and outpatient cancer care processes. The oncology ACO in Miami, FL, is the first commercial ACO of this type, to my knowledge. It is a collaborative venture of Advanced Medical Specialties, Florida Blue, and Baptist Health System.8 A commercial oncology ACO can be an adjunct or carve-in to any other ACO, PHO, PCMH, network, or commercial payer. That said, the jury is out on the ACO model. Although some ACOs have demonstrated shared savings (including half of the groups that participated in the Medicare Medical Group Demonstration Project9 and 19 of 32 Medicare Pioneer ACOs10), no ACO, to date, has demonstrated a return on investment. That is because, to date, ACO infrastructure costs have been greater than the shared savings generated by these programs. Even if there ultimately proves to be some return on investment for ACOs, there is concern that it will cease to exist when cost benchmarks are reset in future years to take into account cost savings achieved in initial contract years. Multispecialty group. Oncologists can form, join, or consolidate with a dominant multispecialty group and operate as a separate division of the larger group. If the multispecialty group has a
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Building the oncology medical home. As discussed in the Preliminary Considerations section, it is likely that oncology groups will need to be able to demonstrate new and better value in the future to optimize financial opportunities with payers. One way to do so is to develop an oncology medical home. The oncology medical home would focus on, among other things, right-siting oncology care; curbing overuse of chemotherapy, radiation therapy, imaging, and surgical services; standardizing use of cost-effective protocols, treatment regimens, and supplies; and proactively monitoring medication adverse events and patient status to avoid avoidable emergency department visits and hospital admissions. Early results from medical home pilots from practices like Oncology Hematology Consultants (Drexel Hills, PA) and Wilshire Hematology Oncology (La Verne, CA) have been encouraging.3-5 The oncology medical home is an approach to the delivery of oncology care that can be adopted by any oncology group, supergroup, or network. To meet the primary care standards of the National Committee on Quality Assurance (NCQA)6 to be recognized as a PCMH, your oncology group must provide first contact; continuous, comprehensive, whole-person care for patients; and treatment for patients through team-based care that is coordinated or integrated across the health system. Wholeperson care includes provision of comprehensive care and selfmanagement support and emphasizes the spectrum of care needs, such as routine and urgent care and mental health as well as advice, assistance, and support for making changes in health habits and making health care decisions. Preventive care is also a key expectation for clinician focus. Accordingly, PCMH certification is reserved by the NCQA principally for primary care practices—including family practitioners, general practitioners, internists, and pediatricians. Oncology practices would qualify as a PCMH only if they provide such whole-patient primary care services for patients for at least 75% of their patients, as some may do. Otherwise, specialist medical groups, like many oncology practices, will only be able to participate in NCQA’s Patient-Centered Specialty Practice Recognition Program.7 This program recognizes specialty practices that have successfully coordinated care with their primary care colleagues as well as with other specialists and that meet the goals of providing timely access to care and continuous quality improvement. Whether, when, and the extent to which payers will reward oncology medical homes for implementing value-based care will vary from payer to payer and from market to market. In that regard, it is prudent not to get too far ahead of the market and implement oncology medical home arrangements (which may reduce use of oncology services) until enough payers are ready to recognize and pay for such value-based care. To hedge
this risk, some oncology medical homes are considering whether to charge a retail membership fee to patients for patient navigation or other value-added services so as to cover any lost fee-for-service revenue opportunity as well as any new oncology medical home costs.
Michael L. Blau
Hybrid arrangements. Oncologists can enter into arrangements that are hybrids of the models discussed in this article. For example, they could form an oncology supergroup among a coalition of the willing. For those who are unwilling to consolidate their practices in this manner, the supergroup could extend its reach by developing a wraparound oncology network. The broader network could develop an oncology medical home or commercial oncology ACO or could join a Medicare ACO. Innovation grants. The Centers for Medicare & Medicaid Innovation (CMMI) was initially appropriated $10 billion by Congress to make innovation grants to pilot new business models for providing value-based care.11 Creative oncologists should consider developing new payment and delivery arrangements for value-based oncology care that could be funded by such an innovation grant. Money may be available to experiment with oncology medical home, oncology ACO, oncology payment bundle, episode-of-care, and/or financially or clinically inte-
grated oncology network arrangements. For example, a $19 million innovation grant from the Centers for Medicare & Medicaid Innovation was awarded to Innovative Oncology Business Solutions (Albuquerque, NM) as the lead organization to form and study the impact of oncology medical homes in six states over a 3-year period.12 The study seeks to prove that patient-centered, private practice cancer centers provide better oncology care at lower cost than alternative sites of care. The only limits to the types of projects that may be funded by such innovation grants are the limits of imagination in designing future systems of oncology care. Acknowledgment Presented in part at the 2013 Cancer Center Business Summit, Chicago, IL, October 24-25, 2013. This article is intended to provide background on the range of options to preserve private practice that oncology groups can consider in meeting the challenges of a rapidly changing health care market. This article is not intended to provide legal advice and should not be relied on for that purpose. Experienced legal counsel should be retained to provide specific legal advice if you want to consider pursuing any these options. Author’s Disclosures of Potential Conflicts of Interest The author(s) indicated no potential conflicts of interest. Corresponding author: Michael L. Blau, Esq, Foley & Lardner, 111 Huntington Avenue, Boston, MA 02199; e-mail: [email protected].
DOI: 10.1200/JOP.2013.001343.
References 1. Reference deleted 2. US Department of Justice, Federal Trade Commission: Statements of antitrust enforcement policy in health care. www.justice.gov/atr/public/guidelines/0000.pdf 3. Bosserman LD: Cancer care initiative #4: Medical oncology home in a mature managed care market. Presented at the 2013 Cancer Center Business Summit, Chicago, IL, October 24-25, 2013 4. Sprandio JD: Building the oncology medical home. Presented at the 2011 Cancer Center Business Summit, Chicago, IL, October 13-14, 2011 5. Sprandio JD: Oncology patient– centered medical home. J Oncol Pract 9:47s49s, 2012 (suppl) 6. National Committee for Quality Assurance: Patient-centered medical home recognition. http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHome PCMH.aspx 7. National Committee for Quality Assurance: Patient-centered specialty practice recognition. http://www.ncqa.org/Programs/Recognition/PatientCenteredSpecialtyPractice Recognition.aspx
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8. Samuels M, Gavras J, Kalman LA: Innovative cancer care initiative #2: The oncology ACO. Presented at the 2013 Cancer Center Business Summit, Chicago, IL, October 24-25, 2013 9. Centers for Medicare & Medicaid Services: Medicare physician group practice demonstration: Physicians groups continue to improve quality and generate savings under Medicare physician pay-for-performance demonstration. http://www.cms.gov/ Medicare/Demonstration-Projects/DemoProjectsEvalRpts/downloads/PGP_Fact_ Sheet.pdf 10. Centers for Medicare & Medicaid Services: Pioneer accountable care organizations succeed in improving care, lowering costs: Model is part of broader HHS efforts to reform the delivery of health care. http://www.cms.gov/Newsroom/MediaReleaseDatabase/ Press-Releases/2013-Press-Releases-Items/2013-07-16.html 11. Center for Medicare and Medicaid Innovation, 42 U.S.C §1315a (a); [email protected] 12. McAneny B, Stevens L, Russo B: Innovative cancer care initiative #1: Community oncology medical home (COME HOME). Presented at the 2013 Cancer Center Business Summit, Chicago, IL, October 24-25, 2013
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sufficient base of primary care physicians, it could qualify to be a Medicare ACO. It could also sponsor development of PCMHs or medical villages. It could develop an oncology medical home as an adjunct to its primary care medical homes. Such a strategy could be particularly successful if the multispecialty group has an adequate base of referring providers to support its oncology division and if the larger group has the resources to be care-ready, risk-ready, and deal-ready. Examples of such groups include Atrius Health (Newton, MA) and Palo Alto Medical Group (Palo Alto, CA).
Perspective
Options for Oncologists to Preserve Independent Private Practice By Michael L. Blau, Esq
Background Market and government reforms are transforming the health care landscape. These changes are being driven by the economic— and some would say social and moral—imperative to reduce the unsustainable rate of growth of health care spending in this country. Those costs make the United States the most expensive health care system in the world; drain federal and state coffers and crowd out other social priorities; strain household budgets and cause an unacceptable rate of medical bankruptcies; and make health care unaffordable or inaccessible for far too many Americans. Oncology is responsible for its fair share of these increasing health care costs. It accounts for up to 10% of all health care expenditures by some estimates.1 And oncology costs are increasing faster than many other health care components because of expensive new drugs1 like Provenge (Dendreon, Seattle, WA), Zytiga (Janssen Biotech, Horsham, PA), and Xtandi (Astellas, Northbrook, IL; Medivation, San Francisco, CA); expensive new molecular diagnostics; and expensive new robotic technologies and therapeutic technologies like proton beam therapy. It has gotten to the point that some patients are as afraid of the out-of-pocket cost of their cancer care as they are of their cancer. Virtually everyone agrees that it is time to seriously reexamine our fragmented, expensive health care system and to innovate sustainable ways to cure its ills. The private market is moving inexorably in this direction through new value-based purchasing and alternative payment arrangements (like pay for performance [P4P], shared savings, bundled payment, episode of care, and global capitation arrangements); through reorganization of providers into accountable care organizations (ACOs), medical homes, and other clinically integrated care organizations that span the full continuum of care and are focused on population health management (PHM); through new health insurance product designs that involve higher patient copays for more expensive care options; through limited, tiered, and exclusive provider networks; through redesign of care delivery processes; and through practice acquisitions and industry consolidation to achieve economies of scale. The offices of health care executives today are replete with talk of bold initiatives to reimagine, redesign, and rebuild our system of so-called sick care, which is focused on acute and episodic care, into the PHM system of the future, which is to be focused on proactively keeping patients healthy. The current pace and extent of planning for the change to PHM and valuebased care is unprecedented, and there is a growing sense of Copyright © 2014 by American Society of Clinical Oncology
urgency—the stakes are high, resources are constrained, and the right investments need to be made before opportunities disappear or are claimed by others. The prospect of change of this magnitude can be exhilarating. It can drive innovation and create new opportunities for community oncology. But it can also be unsettling, breed uncertainty, and create a lot of anxiety. That is what many community-based oncologists report feeling today. They are concerned about reimbursement reductions for chemotherapy, radiation therapy, and imaging; about reduction in demand for elective services as a result of increased patient copays; about being excluded from payer contracting networks because of the relatively high cost of oncology care; about losing referral sources as primary care physicians and other specialists align with specific networks; about the pressure to give up their practice autonomy and become employees of hospitals, strong multispecialty groups, or health systems; about the shift to use of midlevel providers practicing at the top of their license; about whether payers will pay for the transformation to value-based care and personalized medicine or for new state-of-the-art drugs and technologies; and about the projected reduction in need for oncology care under stringent managed care systems that incentivize lower specialist usage rates. In the face of these changes and challenges, communitybased oncologists want to know what strategic options they have to remain independent during the transition to PHM arrangements and to succeed in the more integrated health systems of the future.
Some Preliminary Considerations This article is intended to help oncologists make informed choices about their potential pathway(s) to success in their local markets that preserve some modicum of independent private practice. It addresses ways that oncologists can affiliate with other physicians and medical groups to achieve this end. It does not address affiliations with other parties such as hospitals; health systems; or practice management, health information technology, or private equity/venture capital companies, which may also assist private practice oncologists to remain independent. It is almost a cliche´ to say that all health care is local and that what works in one market may not work in another. There is no one-size-fits-all solution to preserving independent private practice for oncologists. Any successful strategy must respond to the unique stakeholders and competitive dynamics in the locality. That said, it is possible to discern some success factors
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Foley & Lardner, Boston, MA
Michael L. Blau
Critical mass is necessary, but not sufficient, for private practice to continue to be a viable option for oncologists in many competitive markets. To improve your group’s negotiating position, whether as a vendor to other provider organizations or in relation to payers, it may help significantly if your oncology group (or network) is the dominant quality provider of oncology services in your market. If it is, then your group or network may be relatively indispensable to local hospitals, health systems, and payers that are looking for a broad and deep enough bench of oncology providers to meet patient care needs in a conveniently accessible, timely, and high-quality manner. Critical mass also provides some protection against destructive competition, because it makes it more difficult for even a large health system to justify the effort, expense, and risk to try to replicate your capacity. Duplicating your capacity could take considerable time, involve substantial investment and an uncertain outcome, and may ultimately not be successful. The more rational result may be for the health system to do business with your group or network on reasonable (or even premium) terms, whether on a transitional or long-term basis. The pathway to future success is therefore likely to be predicated on your group or network having a critical mass of the quality oncologists practicing in your local or regional market. In some markets, a dominant hospital, health system, or multispecialty group may be too far ahead of you to permit you to catch up. If the quality oncologists or groups in your market have already made contractual commitments that preclude their ability to join you in a larger oncology enterprise, you may ultimately have no choice but to play ball with the dominant system, in some way, and bargain as best you can for your fair share of their business and health care dollars. Where your oncology group or network has the opportunity to assemble and grow to sufficient scale on a regional or statewide basis to gain market significance, the options for doing so are discussed in this article. Even if you can overcome the considerable hurdles to build critical mass in your market, size alone is no longer sufficient to ensure your success. Many payers are offering only general inflation rate increases (ie, currently 2% to 3%) for physician services and are reducing payments for ancillary services. Payers are typically no longer offering to increase payments by the rate of health care cost inflation (which historically has been closer to 5.5%). Payers are generally only willing to offer more than an inflation adjustment if oncology providers can demonstrate 88
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that they can provide a correspondingly better cancer care value proposition. Under new alternative payment contracts, providers can receive additional amounts in the form of bonuses for measurably improving quality and outcomes; shared savings produced by reducing cost and utilization; and/or surpluses generated by budget-based payment bundles, episodes-of-care payments, or capitation arrangements. Negotiating for some combination of general inflation increases and value-based payments (by demonstrating quality and cost-effectiveness) will probably be the best way in the foreseeable future for independent oncologists to position themselves to optimize their bottom-line financial results. The emerging message from the payer community is that oncologists are unlikely to do as well financially in the future without accepting some risk for the quality and cost of care they provide, and doing the real work necessary to redesign care processes and create new value in oncology care. In this regard, community oncology has the opportunity to develop new value by curbing variability and overuse of cancer drugs and therapies; changing physician incentives to select the most cost-effective treatments rather than the most profitable ones; proactively monitoring patients for pain and drug adverse events to avoid avoidable emergency department visits and hospital admissions; and eliminating futile end-of life services. If community oncology groups do these things well, they should have the opportunity to share in the resulting cost savings. So oncology providers who want to remain independent should be “care-ready”—they should be prepared to be engaged, active participants in designing the care protocols, pathways, and care management and coordination processes that will enable the delivery of more efficient and effective cancer care in the health care and oncology care systems of the future. Community oncologists also need to become “risk-ready” and “deal-ready.“ That is, they will probably need to either develop, or affiliate with an organization that has developed, the infrastructure to accept and manage increasing financial risk for the quality and cost of oncology care they provide. Such infrastructure includes the human and technological resources to do such things as track, measure, and report on pathway compliance; manage use of ancillaries and drugs; stratify patients by susceptibility to cost-saving interventions; proactively monitor patients between office visits; support home-based care; provide after-hours care management or navigation; and support endof-life planning and palliative care. Being risk-ready may also involve negotiating risk pool payment arrangements with appropriate withholding, risk-sharing, and surplus-sharing provisions as well as insolvency protections (eg, stop-loss insurance, reinsurance, financial reserves). Being deal-ready requires that the oncology group or network have the executive leadership and skills to identify and execute on strategic transactional opportunities for growth. This may entail recruiting and onboarding oncologists; merging or consolidating with other oncology practices; negotiating with payers, ACOs, primary care medical homes, and employers; accessing sources of capital; and affiliating with hospitals and other health system components.
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that may help guide oncology groups in considering their strategic alternatives. Those success factors include: • obtaining critical mass, • developing a new value proposition, • being in network with as many systems as possible to secure an adequate referral base, • being “care-ready,” • becoming “risk-ready,” • being “deal-ready,” and • getting the timing right for transitioning from fee-for-service payments to risk-based payment arrangements.
Options to Preserve Independent Practice
• economies of scale (eg, insurance, employee benefits, staffing, operations); • improved ability to develop and support ancillary revenue enhancements (eg, imaging, clinical trials, ambulatory surgery); • better resources for strategic and business planning; • central information technology platform and clinical integration; • increased capacity to accept risk for the quality and cost of services and to manage care and use; • greater array of specialized programs and services (eg, medical, radiation, breast, colon, and lung specialists); • quality improvement through peer interaction; and • improved quality of life (eg, more coverage/less call). There are also distinct legal advantages to consolidating separate oncology practices into a single, fully integrated supergroup: • The ability of participating oncologists to jointly price, or collectively bargain, with payers and vendors, without engaging in illegal price fixing in violation of federal and state antitrust laws. • The ability of participating oncologists to refer to one another while sharing an economic relationship and without violating federal and state Anti-Kickback Statutes. • The ability to share ancillary revenue without violating the Stark Law.
Options to Preserve Independent Private Practice Oncology supergroups. One of the factors for success in remaining independent is critical mass in a market. One way to achieve such critical mass is to form an oncology supergroup in a region or state. An oncology supergroup is a fully integrated organization that combines independent oncologists and oncology groups into a single group practice entity that practices under a single tax identification number. To be an oncology supergroup, the organization should have, or plan to include, a sufficient number of quality medical, radiation, specialty, and/or surgical oncologists at a sufficient number of key needed locations to be vital, if not indispensable, to any payer whose members need access to high-quality, affordable oncology care across the region or state. Examples of oncology supergroups include Texas Oncology (Dallas, TX), Florida Oncology Specialists (Fort Myers, FL), and Regional Cancer Care Associates (Hackensack, NJ). There are several structural options for organizing an Oncology supergroup. Those options include a traditional medical group, with standardized operations and a single compensation pool; a holding company that becomes the parent of existing practices with all of the existing physician-stockholders becoming owners and employees of the holding company; or a group practice without walls, with each oncology group operating as a separate division and profit/loss center of a single practice entity. Each structure has different business and legal implications (that are beyond the scope of this article to review). What all of these supergroup arrangements have in common are certain core potential business advantages. They include: • improved market position for recruitment, growth, and future success; • enhanced bargaining power in relation to payers and vendors; • improved access to capital for technology and growth; Copyright © 2014 by American Society of Clinical Oncology
There are, however, antitrust constraints on how large a supergroup can be. Under applicable Federal Trade Commission Safety Zones and Guidances,2 an oncology supergroup can, with impunity, include up to 20% of the oncologists in the relevant geographic market on an exclusive basis (ie, the oncologists can only contract with payers through the supergroup and not on their own or through a competing physician organization) and up to 30% on a nonexclusive basis; a Medicarecertified ACO can contract on a nonexclusive basis with a supergroup that has up to 50% of oncologists. The relevant geographic market for antitrust purposes is generally defined as the area (defined by zip codes) from which the constituent oncology groups draw either 75% or 90% of their patients for such services. It is possible, in the future, that the antitrust enforcement agencies may analyze the geographic market for oncology services more narrowly or may evaluate the service markets for oncology subspecialty services separately (although they have not historically done so). At the bottom line, on the basis of antitrust enforcement agency precedents, if the market for oncology services is relatively fragmented and unconcentrated, a supergroup can probably include up to 40% to 50% of the oncologists in the relevant service market (ie, measured by outpatient ambulatory oncology services and/or inpatient oncology services) and in the relevant geographic market (ie, the 75% or 90% patient draw area) without raising any material antirust concern. This is more than adequate for the supergroup to have an opportunity to succeed in its business objectives, particularly if it is composed of high-quality physicians.
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Getting the timing right for the transition from fee-forservice to value- or risk-based payment arrangements is also a key to success in maintaining a viable private practice. If your oncology group gets too far ahead of the market by aggressively seeking early participation in alternative payment arrangements, you may end up leaving considerable fee-for-service dollars on the table and take a significant hit in physician compensation. Conversely, if your group is too far behind the market in moving to alternative payment and delivery arrangements, you may lose risk-based opportunities to competitors and may not have those opportunities in the future. Once too far behind the market, your group may never be able to catch up. To complicate matters further, the timing of the transition to value and risk-based arrangements may be dictated by specific local market conditions and state regulation. For example, providers in major urban/suburban parts of states like Massachusetts and California may be years ahead of providers in neighboring regions or states in transitioning to alternative payment and delivery arrangements.
Michael L. Blau
There can also be numerous obstacles to consolidating oncology groups into a supergroup:
Of these, different cultures and lack of trust may be the two greatest obstacles that are the most difficult to overcome. Tremendous strides in that direction can be made through an inclusive, engaged, and respectful planning process in collaboratively designing and developing the supergroup. That planning process should address all material structural, governance, operational, technological, and financial design features of the supergroup. Such an inclusive and comprehensive planning process is a key to getting sufficient buy-in for oncology groups to commit to forming the supergroup. Oncology networks. If the obstacles to forming an oncology supergroup prove insurmountable, it may be easier to obtain critical mass by forming a single-specialty contracting network composed of independent oncologists and oncology groups. To be successful, such a network, like a supergroup, would need to include a sufficient number of quality oncologists at a sufficient number of key locations to be vital, if not indispensable, to any payer or health system whose patients need access to high-quality cancer care in their markets. Such a network could be a carve-in (or carve-out) network for any health system, physician-hospital organization (PHO), ACO, or patient-centered medical home (PCMH). Examples of such oncology networks include Cancer Clinics of Excellence and Oncology Resource Networks of America. One obstacle to forming an oncology network is the extent to which oncologists are already under contractual constraints that may prohibit their joining the network. If the oncology group is already a member of a multispecialty independent practice association (IPA), PHO, or ACO, the group may have already contracted away its ability to join another network, at least until it can terminate its existing contract. Oncology groups also need to assess whether they will lose referral sources if they leave their current IPA, PHO, or ACO to join an oncology network. This concern may resolve on its own over time if the oncology network is successful in becoming an adjunct or carve-in to multiple contracting organizations, including those with which the oncology group currently participates. To be able to bargain collectively with payers under such network arrangements, the participating oncology groups 90
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• Different cultures. • Different information technology platforms (especially if the group has undergone a recent information technology conversion). • Different billing arrangements. • Different debt profiles. • Different payment contracts/rates. • Different practice values. • Different use of midlevel providers. • Different staff salary and benefit structures. • Different buy/sell arrangements. • Different quality and use profiles. • Lack of trust.
would need to be sufficiently financially and/or clinically integrated for antitrust purposes.2 Financial integration consists of sharing substantial financial risk.2 Examples include capitation agreements, withhold pools, global fee, certain payment bundles, episodes of care, case rates, and certain bonus arrangements. A key to a substantial financial risk arrangement is that there must be shared risk—that is, a substantial portion of the oncologist’s payment must be based on the aggregate performance of all physicians in the network (or risk pool) and not just based on individual quality or use performance. Programs, like the Medicare Physician Quality Reporting Initiative program provide bonuses for individual physician quality performance and therefore do not involve substantial shared financial risk and would not qualify the network as a financially integrated network for single-signature contracting. Nor do indemnity, fee-for-service, or preferred provider organization payment arrangements involve shared financial risk. In contrast, clinical integration focuses on the quality control, information systems, and protocols established by the physician network that lead to increased quality, efficiency, and modification of use and practice patterns.2 The use of clinical practice guidelines help qualify a network as clinically integrated. This is because use of clinical pathways reflects an effort to have all network physicians follow best clinical practice, reduce variation in care, and standardize quality care to the extent feasible. Coupled with utilization review targeted at compliance, use of clinical guidelines can demonstrate that the network is coordinating care to achieve higher quality and/or lower costs, thereby distinguishing itself by delivering better (and procompetitive) value-based care to patients. The Department of Justice and the Federal Trade Commission define clinical integration as “integration [that] can be evidenced by the network implementing an active and ongoing program to evaluate and modify practice patterns by the network’s physician participants and create a high degree of interdependence and cooperation among the physicians to control costs and ensure quality. This program may include: (1) establishing mechanisms to monitor and control utilization of health care services that are designed to control costs and assure quality of care; (2) selectively choosing network physicians who are likely to further these efficiency objectives; and (3) the significant investment of capital, both monetary and human, in the necessary infrastructure and capability to realize the claimed efficiencies.”2(p91) To achieve sufficient clinical integration, the oncology network must commit to a serious effort to establish goals relating to the quality and use of oncology services; to monitor participants’ performance concerning these goals; and to take concrete steps, where necessary, to modify participants’ actual practices. To do so, the network will need to make significant investments in information systems, data analysis and reporting capabilities, and the human and administrative resources necessary to implement these programs. The principal downside to an oncology network is that if it does not achieve substantial financial and/or clinical integration, then it can be easily bypassed by payers. Absent sufficient
Options to Preserve Independent Practice
integration, the network would not be able to contract on a single-signature basis and would not be able to bind its participating oncologists to contracts. As such, payers could elect not to recognize the network as a legitimate bargaining agent and could insist on contracting separately with each participating oncology group. By this means, payers could divide and conquer the network.
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Oncology ACO. Oncologists can join a Medicare ACO or may be able to form their own oncology-only commercial ACO. Oncologists can sign up to participate in Medicare ACOs that participate in the Medicare Shared Savings Program (MSSP). These are principally primary care– oriented organizations, and oncologists would need to bargain hard for meaningful governance rights and for a fair allocation of cost savings, performance-based bonus payments, and risk pool surpluses. Generally, oncologists will not be able to form an oncologyonly Medicare-certified ACO for MSSP purposes. That is because Medicare fee-for-service patients are assigned to a Medicare ACO based on the primary care physician from whom they receive most of their primary care services. Patients are not assigned to an MSSP-participating ACO based on their oncologist or other specialist physician unless the patient does not have a primary care physician and receives most of the patient’s primary care services from an oncologist or specialist. That would rarely be the case. Accordingly, as a practical matter, there cannot be an oncology-only ACO for MSSP purposes. Enterprising oncologists, however, may be able to design and implement an oncology-only ACO to do business with commercial insurers. Such a commercial oncology ACO would include a health system partner (and potentially other cancer care continuum providers) and an interested commercial insurer. The commercial insurer would pay for the value produced by the oncology ACO in reducing costs and improving quality (such as described in the oncology medical home model), while the health system partner would work with the oncologists on transitions of care and in redesigning value-based inpatient and outpatient cancer care processes. The oncology ACO in Miami, FL, is the first commercial ACO of this type, to my knowledge. It is a collaborative venture of Advanced Medical Specialties, Florida Blue, and Baptist Health System.8 A commercial oncology ACO can be an adjunct or carve-in to any other ACO, PHO, PCMH, network, or commercial payer. That said, the jury is out on the ACO model. Although some ACOs have demonstrated shared savings (including half of the groups that participated in the Medicare Medical Group Demonstration Project9 and 19 of 32 Medicare Pioneer ACOs10), no ACO, to date, has demonstrated a return on investment. That is because, to date, ACO infrastructure costs have been greater than the shared savings generated by these programs. Even if there ultimately proves to be some return on investment for ACOs, there is concern that it will cease to exist when cost benchmarks are reset in future years to take into account cost savings achieved in initial contract years. Multispecialty group. Oncologists can form, join, or consolidate with a dominant multispecialty group and operate as a separate division of the larger group. If the multispecialty group has a
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Building the oncology medical home. As discussed in the Preliminary Considerations section, it is likely that oncology groups will need to be able to demonstrate new and better value in the future to optimize financial opportunities with payers. One way to do so is to develop an oncology medical home. The oncology medical home would focus on, among other things, right-siting oncology care; curbing overuse of chemotherapy, radiation therapy, imaging, and surgical services; standardizing use of cost-effective protocols, treatment regimens, and supplies; and proactively monitoring medication adverse events and patient status to avoid avoidable emergency department visits and hospital admissions. Early results from medical home pilots from practices like Oncology Hematology Consultants (Drexel Hills, PA) and Wilshire Hematology Oncology (La Verne, CA) have been encouraging.3-5 The oncology medical home is an approach to the delivery of oncology care that can be adopted by any oncology group, supergroup, or network. To meet the primary care standards of the National Committee on Quality Assurance (NCQA)6 to be recognized as a PCMH, your oncology group must provide first contact; continuous, comprehensive, whole-person care for patients; and treatment for patients through team-based care that is coordinated or integrated across the health system. Wholeperson care includes provision of comprehensive care and selfmanagement support and emphasizes the spectrum of care needs, such as routine and urgent care and mental health as well as advice, assistance, and support for making changes in health habits and making health care decisions. Preventive care is also a key expectation for clinician focus. Accordingly, PCMH certification is reserved by the NCQA principally for primary care practices—including family practitioners, general practitioners, internists, and pediatricians. Oncology practices would qualify as a PCMH only if they provide such whole-patient primary care services for patients for at least 75% of their patients, as some may do. Otherwise, specialist medical groups, like many oncology practices, will only be able to participate in NCQA’s Patient-Centered Specialty Practice Recognition Program.7 This program recognizes specialty practices that have successfully coordinated care with their primary care colleagues as well as with other specialists and that meet the goals of providing timely access to care and continuous quality improvement. Whether, when, and the extent to which payers will reward oncology medical homes for implementing value-based care will vary from payer to payer and from market to market. In that regard, it is prudent not to get too far ahead of the market and implement oncology medical home arrangements (which may reduce use of oncology services) until enough payers are ready to recognize and pay for such value-based care. To hedge
this risk, some oncology medical homes are considering whether to charge a retail membership fee to patients for patient navigation or other value-added services so as to cover any lost fee-for-service revenue opportunity as well as any new oncology medical home costs.
Michael L. Blau
Hybrid arrangements. Oncologists can enter into arrangements that are hybrids of the models discussed in this article. For example, they could form an oncology supergroup among a coalition of the willing. For those who are unwilling to consolidate their practices in this manner, the supergroup could extend its reach by developing a wraparound oncology network. The broader network could develop an oncology medical home or commercial oncology ACO or could join a Medicare ACO. Innovation grants. The Centers for Medicare & Medicaid Innovation (CMMI) was initially appropriated $10 billion by Congress to make innovation grants to pilot new business models for providing value-based care.11 Creative oncologists should consider developing new payment and delivery arrangements for value-based oncology care that could be funded by such an innovation grant. Money may be available to experiment with oncology medical home, oncology ACO, oncology payment bundle, episode-of-care, and/or financially or clinically inte-
grated oncology network arrangements. For example, a $19 million innovation grant from the Centers for Medicare & Medicaid Innovation was awarded to Innovative Oncology Business Solutions (Albuquerque, NM) as the lead organization to form and study the impact of oncology medical homes in six states over a 3-year period.12 The study seeks to prove that patient-centered, private practice cancer centers provide better oncology care at lower cost than alternative sites of care. The only limits to the types of projects that may be funded by such innovation grants are the limits of imagination in designing future systems of oncology care. Acknowledgment Presented in part at the 2013 Cancer Center Business Summit, Chicago, IL, October 24-25, 2013. This article is intended to provide background on the range of options to preserve private practice that oncology groups can consider in meeting the challenges of a rapidly changing health care market. This article is not intended to provide legal advice and should not be relied on for that purpose. Experienced legal counsel should be retained to provide specific legal advice if you want to consider pursuing any these options. Author’s Disclosures of Potential Conflicts of Interest The author(s) indicated no potential conflicts of interest. Corresponding author: Michael L. Blau, Esq, Foley & Lardner, 111 Huntington Avenue, Boston, MA 02199; e-mail: [email protected].
DOI: 10.1200/JOP.2013.001343.
References 1. Reference deleted 2. US Department of Justice, Federal Trade Commission: Statements of antitrust enforcement policy in health care. www.justice.gov/atr/public/guidelines/0000.pdf 3. Bosserman LD: Cancer care initiative #4: Medical oncology home in a mature managed care market. Presented at the 2013 Cancer Center Business Summit, Chicago, IL, October 24-25, 2013 4. Sprandio JD: Building the oncology medical home. Presented at the 2011 Cancer Center Business Summit, Chicago, IL, October 13-14, 2011 5. Sprandio JD: Oncology patient– centered medical home. J Oncol Pract 9:47s49s, 2012 (suppl) 6. National Committee for Quality Assurance: Patient-centered medical home recognition. http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHome PCMH.aspx 7. National Committee for Quality Assurance: Patient-centered specialty practice recognition. http://www.ncqa.org/Programs/Recognition/PatientCenteredSpecialtyPractice Recognition.aspx
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8. Samuels M, Gavras J, Kalman LA: Innovative cancer care initiative #2: The oncology ACO. Presented at the 2013 Cancer Center Business Summit, Chicago, IL, October 24-25, 2013 9. Centers for Medicare & Medicaid Services: Medicare physician group practice demonstration: Physicians groups continue to improve quality and generate savings under Medicare physician pay-for-performance demonstration. http://www.cms.gov/ Medicare/Demonstration-Projects/DemoProjectsEvalRpts/downloads/PGP_Fact_ Sheet.pdf 10. Centers for Medicare & Medicaid Services: Pioneer accountable care organizations succeed in improving care, lowering costs: Model is part of broader HHS efforts to reform the delivery of health care. http://www.cms.gov/Newsroom/MediaReleaseDatabase/ Press-Releases/2013-Press-Releases-Items/2013-07-16.html 11. Center for Medicare and Medicaid Innovation, 42 U.S.C §1315a (a); [email protected] 12. McAneny B, Stevens L, Russo B: Innovative cancer care initiative #1: Community oncology medical home (COME HOME). Presented at the 2013 Cancer Center Business Summit, Chicago, IL, October 24-25, 2013
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sufficient base of primary care physicians, it could qualify to be a Medicare ACO. It could also sponsor development of PCMHs or medical villages. It could develop an oncology medical home as an adjunct to its primary care medical homes. Such a strategy could be particularly successful if the multispecialty group has an adequate base of referring providers to support its oncology division and if the larger group has the resources to be care-ready, risk-ready, and deal-ready. Examples of such groups include Atrius Health (Newton, MA) and Palo Alto Medical Group (Palo Alto, CA).
