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Dr. Kavitha Jennifer Ramchandran, Clinical Associate Professor, Medicine - Oncology at Stanford University. Her clinical focus is in Thoracic oncology and palliative medicine. Dr. Ramchandran served on the Planning Committee for ASCO’s Palliative Care in Oncology Symposium and is here to talk about the event.

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Communicating with Patients about Financial Toxicity: Dr. Ryan Nipp

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ASCO Daily News by American Society Of Clinical Oncolo.. - 1M ago
Dr. Heather McArthur, medical director of breast oncology at Cedars-Sinai Medical Center, discusses combination radiotherapy/immunotherapy treatments aimed at increasing survival outcomes of patients with breast cancer that has metastasized to the brain.
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ASCO Daily News Podcast Title: ASCO Quality Care Symposium: Key Takeaways from the Meeting with Ethan Basch, MD

ASCO Daily News - Ethan Basch, MD The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

[MUSIC PLAYING] Welcome to the ASCO Daily News Podcast. I'm Lauren Davis. And joining me today is Dr. Ethan Basch of the University of North Carolina. He's both a medical oncologist and a health services researcher. Dr. Basch has clinical expertise in prostate cancer. And his research includes patient-reported outcomes, drug regulatory policy, and comparative effectiveness research. Dr. Basch, welcome to the podcast.

Nice to be here.

So you've just returned from the Quality Cancer Symposium. How was this event different from previous years?

The symposium this year was really superb. It was very well attended by a mix of quality officers, clinicians, and researchers. And to me, what was really striking about this year's meeting is that people are really doing applied projects that are multidisciplinary. And what I mean by this is that, in prior years, we'd see very small pilot projects in very narrow areas. We would see projects that maybe were being done just by researchers or projects just being done by community clinicians.

But what we're really seeing now is this coming together of research and practice with a focus on value-based care. And the projects that are being done are very sophisticated and are spanning the continuum from identifying a problem in practice to developing a quality project to measuring and then modifying the outcomes. And so that's really a very exciting development, where we see the research and practice coming together.

What would you say are some of the take-home messages about innovations in care delivery that resonated with you or folks that you spoke with?

I'd say the biggest message from the meeting this year is, it can be done. When there are quality projects that focus around some of the value-based care topics that have risen to the top at this meeting, it was very clear that it is feasible to set up programs and to enlist stakeholders and to actually execute in these areas. For example, there were projects focused around financial toxicity and counseling, around reducing low quality treatment, around navigation, coordination of care, unnecessary ER visits and hospitalizations. And in all of these areas, there was the ability to gather data, develop programs, implement those programs, and collect data. So it could be done.

I think the other take-home message is that there is an increasing number of quality roles in health systems for using data. It used to be that these kinds of roles around value-based care delivery and quality were maybe performed by those who were doing other functions within an organization. And there are an increasing number of dedicated personnel for carrying on this work. Financial toxicity, you just touched on, affects all aspects of cancer care. Are there areas where quality of care is improving despite costs of treatments and services?

So I think that that's a challenging question to answer, because it is a heterogeneous landscape. I mean, certainly, there are areas where quality continues to improve that's disconnected from cost. But what's clear is that it's becoming harder and harder to devote resources to improving quality of care when cost is going up. And of course, when we think about value, value is quality over cost. And so as your cost increases, you have to improve quality that much more in order to provide value.

There were interesting data presented at the meeting showing that more than half of patients with cancer experience substantial financial distress that affects their decisions and compliance, their workplace, and the way that they conduct their lives. And there were practical examples of financial navigation programs that can be integrated into practices to help patients, both to deal with their financial situations and also to deal with their distress that they feel due to financial pressures.

However, it's pretty clear from the evidence that was provided that if costs do not start to become contained, it will become not only difficult to continue to be able to devote resources to quality-- because the resources will be going elsewhere-- but it will be very difficult to help patients to manage their own distress or to ensure that people will be compliant with treatments that require increasing out-of-pocket costs.

Absolutely. In your clinical experience with patients who have cancer, do you think people speak up enough about their needs and expectations?

So unfortunately, research has shown that we, as providers, remain unaware of many of the needs and expectations of our patients. There actually was terrific work from a group in Canada presented at the meeting, at the Quality Symposium, presenting some new quality metrics around patient-centeredness that moved beyond our typical patient satisfaction or patient experiential questionnaires that many of our hospital systems use.

And these metrics look at the extent to which patients feel that their needs and their expectations are being understood and acted upon by care teams. And they found, actually, quite a bit of variability between practices. And they are now intervening at individual practice levels in order to try to see if enhanced navigation services can improve that dimension of care delivery.

That's great. So in our modern age, we have so many communication devices and apps at our hands. But what would you say is the best way to find out how patients are doing and experiencing treatment?

Well, there's a lot of interest in patient-reported outcomes and other electronic communication approaches that can connect practices to patients. As I alluded to in the prior question, it's very common that the practices aren't aware of how patients are feeling, either their side effects of treatment or other symptoms related to disease. And these are missed up to half the time. And so this is a big opportunity.

At this point, I think it's unclear what approach is going to prevail in the end. Will this be part of the patient portal that people can download onto their smart device? Will this be standalone programs that can then send messages to providers? I think it's very early in the days of these kinds of technologies.

But I think that what's exciting is that so many patients are using various kinds of devices to track themselves or to communicate with providers. And I think what we'll see in the years ahead is practices and health systems capitalizing upon this Fitbit culture in order to harness that information for clinical care. But again, I think we're really in early days of this movement.

 

That's great. Again, my guest today has been Dr. Ethan Basch. Thank you for joining us.

Thank you. I would just like to thank my colleagues, who were instrumental in putting the meeting together, including my colleague, Dr. Monika Krzyzanowska, who was this meeting's chair-- this year's meeting chair-- Dr. Michael Neuss, who was last year's chair. And the two of them were really key to putting together the agenda, as well as our entire group for planning. But I'd also like to thank Carli Gurtshaw and Tony Schweizer at ASCO, who were the staff members who really brought the whole meeting together. And to our listeners, thank you for tuning in to the ASCO Daily News Podcast. If you're enjoying the content, we encourage you to rate us and review us on Apple Podcasts. [MUSIC PLAYING]

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Harvey Bichkoff, CEO of Marin Cancer Care, has been an administrator at both public and private hospitals for many years before joining this integrated center that provides cancer care with compassion. In this podcast he will discuss the challenges for oncology practices to remain independent in the era of consolidation.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

Welcome to the ASCO Daily News podcast. I'm Lauren Davis, and joining me today is Harvey Bichkoff, CEO of Marin Cancer Care in California. Mr. Bichkoff has been an administrator at both public and private hospitals for many years before joining this integrated center that provides cancer care with compassion. In this podcast we will discuss the challenges for oncology practices to remain independent in the era of consolidation. Mr. Bichkoff, welcome to the podcast.

Thanks very much, Lauren. It's an honor to be here and talk about this important topic.

The 2016 Community Oncology Practice Impact Report shows that since 2008 nearly 1,600 community practices and/or clinics nationally have been affected by closings, hospital acquisitions, and corporate mergers. This is a rate of 15.1 community practices affected per month. What are some of the reasons for this increase? It's been a real challenge for independent practices to maintain their operations over the last few years. There is tremendous pressure from hospitals that are trying to acquire oncology practices. They're doing this to subsidize other acquisitions that they've made and losses from their operations. Some hospitals give significant drug discounts from something called 340B pricing, they often have better commercial contracts, and sometimes have medical foundations that are made up of most of the referring specialists and primary care doctors.

Also, some oncology groups have seen declines in their reimbursement, maybe due to changes in peer mix, or more Medicare patients, as well as increases in their overhead costs. These factors may lead to selling to a hospital, and lock in or maybe increase the physician's income for a few years.

There are risks to giving up autonomy to the hospitals. Physicians may not be able to spend as much time with their patients, they lose control over staffing decisions, and their income guarantees are often short-term, and have to be renegotiated after they've lost leverage.

They may also lose some key employees. The new hospital employer may reduce employee salaries and benefits which could result in turnover. Finally, new acquired oncology practices may feel lost in a larger system where the emphasis may be on growth of market share and profits rather than patient, employee, and doctor satisfaction.

Consolidation seems to be a trend in cancer care, but what are some of the benefits for private practices to remain independent? The primary advantages of remaining independent is that doctors have more control over their time spent with patients, employee hiring and firing decisions, and control over their budget. Some commercial peers are starting to realize that it is beneficial to pay independent doctors more so that they can remain independent, versus paying the hospitals who charge a great deal more for the same services.

I've also heard from colleagues around the country that it can be extremely difficult to renegotiate their salaries after the initial term. If the hospital is not doing as well financially it could impact the group. They can also experience reductions in benefits and retirement contributions. Once the practice is sold it is competing with other hospital departments for their budget.

Other significant advantages are the ability to make quick policy and process decisions. Hospitals are much more bureaucratic and often have several layers of management, which can stall decision-making.

Despite the increasing wave of acquisitions by larger practices or by hospitals, many established private practices wish to remain so. What are some of the challenges to do that?

As you said, the consolidation of medical groups, as driven by hospitals, health care systems and academic centers, has made it very tough on independent practices. Also the aging of the population and increases in Medicare patients where we are lucky to break even is much more difficult.

Our market is also somewhat unique. We have a good peer mix, but extremely high housing costs. This makes it difficult to recruit locally, as unemployment is very low and people can't afford to live here. There are also projected shortages of oncologists and oncology nurses. Lately we've had a hard time finding experienced oncology nurses, and we've had to train our new nurses with less experience.

Another significant challenge, which is particularly worse in cancer, is burnout. We've worked with an expert in the field who's talked with both our staff and doctors about techniques to increase resiliency.

Are there specific ways to be cost effective and keep practice costs down?

Our biggest costs are drugs, staff, and rent. We monitor costs and cash flow carefully. The doctors and the management team regularly meet, and everyone is engaged. We also watch our drug costs carefully, and have our distributors match prices when better pricing is available on the market. We also buy extra drugs when cash pemits before the manufacturer increases prices. Finally, we bid out our drug and supply costs every couple of years to make sure the pricing is competitive. As far as rent goes, we locked in a long-term lease so we know our future costs. And in some instances, you are able to also negotiate tenant improvement allowances on rental deals. As it relates to staffing, we are members of ASCO's PracticeNET. We benchmark our practice against other oncology groups. We found that we are efficient but higher cost. We invest in our employees, and have lower turnover, and outstanding patient satisfaction results. We are in a high-cost area, but believe we should pay a premium because working in cancer is tougher than other specialties. We also cross-train our staff to cover sick days and vacations. We're very fortunate to have great and committed a team of employees. Marin Cancer Care offers integrative medicine, everything from acupuncture to music therapy. What's your secret, especially considering that integrative medicine is both desirable and in demand. How can practices offer these options while still doing more with less? That's a good question, Lauren, and it's been a challenge for us. We started a integrated program in our practice over 20 years ago, as one of our physicians had a passion for these services based on his own personal experience. He's since retired, and one of our new physicians, who also has a commitment to the program, has allowed it to continue to grow and prosper. I think the most important element is having a physician that is committed to these programs. Over the past several years we've had a co-management agreement with our hospital. They pay us for administrative time, and to run the integrative and cancer program overall. The hospital has been extremely committed to the integrative medicine program. They've hired several navigators in the areas of breast, prostate, GI, and survivorship. They've supported the lung cancer screening program. And recently hired palliative care physicians and mid-level providers. It will be very difficult for us to do this on our own, and have a robust integrated program without the hospital support. Absolutely. What are some key steps for private practices to innovate and survive?

I think the primary way to innovate and survive is to always put the patients and their families first. We hire staff who are genuinely interested in customer service, and clinicians who are focused on patient-centered care. We have an excellent reputation for quality and good relations with the local academic medical centers. We were the first practice to join ASCO's CancerLinQ, and are accredited by a national organization, the AAAHC. We're always involved in multiple quality initiatives on how to improve patient care. Our practice has also invested in an experienced management team. It seems like most successful practices have made that investment. We talked a little bit about the cost side minutes ago. It may be even more important to talk about the revenue side. We are paid fairly well by our commercial carriers, and we look at them as partners. We know many of the medical directors who vouch for our quality after analyzing our cost data, and they're willing to pay us more based on our evidence-based practice of medicine. This is extremely important as costs rise and the markets get more competitive.

Finally, it's not easy to turn back once you've sold. It is costly to create a work force, and difficult to renegotiate commercial contracts. Some doctors are biting the bullet and starting over due to their dissatisfaction with their hospital partners.

Thank you so much. Again, my guest today has been Mr. Harvey Bichkoff. Thank you for joining us.

Thanks for the opportunity, Lauren. I hope it's helpful to other independent practices. Thank you. And to our listeners, thank you for tuning in to the ASCO Daily News podcast. If you're enjoying the content we encourage you to rate us and review us on Apple podcast.

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ASCO Daily News by American Society Of Clinical Oncolo.. - 1M ago

Heather L. McArthur, MD, MPH, of Cedars Sinai Medical Center, discusses advances in the treatment landscape for patients with triple-negative breast cancer. 

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