BY KYLE GRABOWSKI

DENVER BUSINESS JOURNAL

America's approximately 10,000 oncologists rely on Medicare payments for 50 to 60 percent of their Income, more than most other specialists.  Jim Musslewhite, president and CEO of Oncology Convergence in Lakewood, runs one of the few companies In the nation that provides help to oncologists in dealing with the unique challenges they face In giving care to cancer patients. Oncology Convergence helps physicians get reimbursed by Insurance companies, telling them which treatments are covered.  “We take the burden of getting paid off their table”, Musslewhite said.  The company also provides consulting services to help oncologists be more efficient in their billing and Insurance-claim submission processes.

Musslewhite bought Oncology Convergence In 2006.  At the time it provided only billing services and was called PK Medical Administrative Services Inc.  Oncology Convergence was doing "OK" financially then, Musslewhite said, but "struggled with technology.”  

The company was running on an antiquated billing platform and was behind In IT Infrastructure, so Musslewhite focused on refurbishing it, adding encrypted email and using software that can access hospitals’ information securely. "You have to have an IT platform that can protect clients' Information," Musslewhite said.  Musslewhite’s company uses patent pending software that it developed, which helps oncology and radiology practices manage changing reimbursement rates, identify where procedures are going unbilled and control re-billing practices. 

 Four years ago, Musslewhite merged his company with Mark Maynard's consulting firm, Trimanus Consulting, to create Oncology Convergence; Maynard Is chief operating officer.  Oncology Convergence's revenue has increased by 400 percent in the six years that Musslewhite has owned the company, going from the low seven figures to mid-seven figures.  During the last three years, the company's client base has increased by more than 500 percent.

 When Musslewhite bought the company, it served clients only In Colorado. Now it has clients In Colorado, Kansas and Arizona, and does consulting work "from coast to coast," according to Musslewhite.

 The company's largest and most recognizable client is the University of New Mexico Cancer Center, which became a client of Oncology Convergence In 2009.  Oncology Convergence has offices in both Lakewood and Tempe, Arizona.  Musslewhite’s primary focus is on helping oncologists. "The federal government dictates how a medical oncologist is paid more than any other specialist," he said.  They just want to treat their patients. Oncology is a small subspecialty, and their voice isn't loud enough because there aren't a lot of them."

Outside the office, Musslewhite writes articles on reimbursement topics for the Hematology Oncology News and Issues, which is designed to help physicians make the best decisions for their practices and patients.

Amednews.com posted an article on Monday to discuss planned RAC audit expansions by the end of this year.  The Patient Protection and Affordable Care Act requires CMS to include in the audit umbrella Medicare Advantage, the Medicare drug benefit and Medicaid in addition to the current Medicare design.  The article notes that, “Earlier this year, President Obama called for expanding payment recapture audits throughout the federal government to improve payment accountability.” 

The president and CEO of HealthDataInsights, the Medicare RAC for audit region D, also mentioned expansion into the Veterans Health Administration and Tricare.  “To the extent that we can accelerate the national RAC program…speedy returns to the Medicare trust fund will be achieved,” she noted. 

This expansion would certainly be a huge benefit to the government, but issues persist.  Despite the looming Medicaid inclusion deadline, the director and CFO of CMS’ Office of Financial Management, Deborah Taylor, explained the difficulties they face in meeting that target.  Indeed, she noted, “We are still in the planning stages,” due to the fact that there are 50 state programs in Medicaid with which CMS needs to coordinate efforts.

Still, with the Medicare overbill recapture dollars growing from $54 million in the first year to $247 million in the second, plus the promise to help fund the recent healthcare bill overhaul with such RAC audit programs, pressure on CMS will be intense to meet the required deadline.  CMS has met some of the bill’s targets and are close to others.  For example, the requirement to expand the Medicare RACs to all 50 states has been met, and Taylor asserted they are far along with implementing the prescription drug benefit into the program.

In response to physician complaints which arose during the demonstration phase of the RAC audits, CMS has added many changes to the Permanent RAC program.  Amednews added a chart to the article that demonstrates those changes.  I’ve copied it below:

Source: Centers for Medicare & Medicaid Services Office of Financial Management

The bottom line is that the RACs are here to stay.  In addition to seeking and charging with crimes the overtly fraudulent Medicare schemes, they are also going after the unintended overbills arising from simple coding errors and rule misunderstandings.  Few specialties can surely be impacted by such audits as oncology, particularly with regard to Medicare.  With the volume of Medicare patients oncologists see and the complicated coding rules, it would be wise to be prepared for such an eventuality.

The Association of Community Cancer Centers’ annual members’ survey, “Cancer Care Trends in Community Cancer Centers”, reveal cost cutting measures and delays in large expenditures in weathering the economic recession.  In a press release posted July 15, 2010, the ACCC reports their key findings, including the following:

• Majority of respondents have enacted hiring freezes, while smaller percentages have actually reduced staff and cut services.  Despite such cost-cutting measures, 78% report, “…their cancer program’s financial status as good or very good,” with only 7% responding that it is “poor”.
• Large capital equipment purchases represent a mixed bag.  While such big ticket purchases as linear accelerators and ultrasound imaging machines have been delayed, some equipment and cancer service line offerings such as IMRT and robotic surgical systems have increased over last year.
• More patients are in need of financial assistance in affording meds, co-pays and transportation.  And, an overwhelming 73% of respondents are seeing an increase in uninsured and underinsured patients.
• Consolidation in hospitals, cancer centers and oncology physician practices is on the rise.
• Fewer private practice oncologists are in contractual relationships with cancer centers, as many physicians opt to be employees of a hospital.
• Use of EMRs jumped by 21 percentage points in one year, and many providers use more than one EMR software program.
• Oral chemotherapeutic agent use is low, up only 3 percentage points over the previous year. 

In 2005 CMS implemented their new chemotherapy drug reimbursement rules based on Average Sales Price rather than the previous method using Average Wholesale Price, reducing reimbursement from a 1.22 to a 1.06 payment-to-cost ratio, as we are all well aware.  American Medical News is reporting results of a recent study of chemotherapy treatments lung cancer patients received post CMS rule implementation.

The study found that the numbers of patients who were treated with chemotherapy actually went up since that payout change.  However, the use of drugs that maintained higher payouts increased while usage of drugs with lower reimbursement decreased.  Two of the study authors, Joseph P. Newhouse, who is an economist and health policy professor at Harvard University in Massachusetts and Mireille Jacobson, who is a senior health economist at RAND Corporation in Santa Monica, CA, provided their conclusions based on the results they found.  Newhouse commented that, "It looks like the oncologists substituted toward the agents whose prices had fallen the least."  Jacobson cautioned, “lawmakers should consider such behavioral responses to payment cuts before they consider implementing more of them. ‘Changing prices alone is just one piece of the puzzle.’  She goes on to say, "We're not suggesting that physicians only take into account payments when they make clinical decisions."

Indeed, Allen Lichter, MD, CEO of ASCO, questions the validity of the authors’ conclusions based on a relatively low (2%) increase in overall chemotherapy usage in lung cancer patients.  He identified numerous considerations an oncologist must make when choosing an appropriate chemotherapeutic agent, pointing out, "It's naïve to think the actual cost of the drug is the only factor."

It appears more research must be done before CMS decides to make another sweeping reimbursement change.  Lawmakers would do well to take their time on this issue.

Back in February, I reported key findings in a study commissioned by COA and performed by Avalere to examine roadblocks to oral Oncolytic usage.  Included in their recommendations for practices that wish to prescribe them rather than infuse them the traditional way were the following suggestions as short term solutions to access issues:

(1) Oncologists should dispense oral oncolytics from in-office pharmacies,

(2) Health plans either should include a medical oncologist on their pharmacy and therapeutics committees or should consult with one,

(3) A patient’s oncology care team should include a dedicated financial counselor, and

(4) Oncologists should take advantage of health information technology, including electronic medical records.

Avalere’s long-term suggestions included, “…the creation of a universal patient-assistance program and an oncology-specific benefit, as well as shifting oral oncolytics from the pharmacy benefit to the medical benefit.”

In response to those above-mentioned solutions, Bill Sullivan, principal consultant for Specialty Pharmacy Solutions LLC, offers his comments, as reported by Angela Maas, Managing Editor for AISHealth.com (http://www.aishealth.com/Bnow/hbd042110.html).  He first takes issue with in-office pharmacy dispensing, noting that only larger practices have the wherewithal to cover the operating costs.  Patrick Cobb, M.D., president of COA, agrees that smaller practices cannot afford such a setup, plus some states don’t allow them, anyway.  Sullivan also defends leaving oral oncolytics within the pharmacy benefit rather than medical due to the “…added specificity and data tracking enabled through the NDC adjudication process [that is part of pharmacy benefits] would be significantly preferred to the antiquated J-code billing system [what medical benefits use], which most agree is ill-suited for care management purposes.” 

While insurance coverage issues are yet to be worked out, Sullivan insists specialty pharmacies have, “…more than enough capacity to support the growing oral oncolytics market.”

Just this week I posted an article explaining key points of the HITECH Act and EHR conversion.  With hospital incentive payouts set to begin October 1, 2010, and physician payouts January 1, 2011, most providers won’t be able to qualify for those initial dollars.  Beacon Partners, a consulting group, commissioned a survey of executives from 168 healthcare organizations to gauge the extent of EHR preparedness.  While the respondents work for hospitals, the findings can surely be extrapolated to private practices, too.  You can view the slideshow of results at this site: http://www.beaconpartners.com/ehradoption/BeaconPartners_EHR_AdoptionStudy.pdf.

Some key findings include the optimal level of Medicare patients to make the HITECH Act incentives worthwhile, driving forces behind EHR adoption, extent of completed EHR conversion, obstacles in completion and increased employment expectations. 

Some good news to oncology-focused organizations is that providers with anywhere from 41%-75% of their revenue from Medicare will benefit from the incentives.  As this is often the case with oncologists, it is certainly worthwhile to convert to EHR sooner rather than later in order to maximize incentives.  Moreover, the study notes that in those hospitals with the highest physician EHR-adoption rates, patient satisfaction is also on the rise.  Given that by far the most important reason stated for implementing an EHR system is improving patient care (by more than forty percentage points over receiving stimulus funds), the knowledge that patient satisfaction increases post-conversion is encouraging.

A minority of the executives surveyed reported having implemented some form of EHR system but are by no means complete.  They reported that, “These early adopters have migrated from paper to a hybrid record system and are moving along the journey to an EHR.”  At the same time a majority comment that their biggest obstacle to EHR adoption concerns their own internal resources (such as change management and clinical workflow integration).  Nearly half note that they don’t have the necessary resources to successfully implement EHR.

When asked how they expect the implementation to be handled, a project management approach throughout the whole process was preferred.  A majority plan to hire more employees for the conversion or to outsource the project. 

The authors note,

Healthcare organizations…will need a full-service firm with a service excellence philosophy to support their patient care strategy and align the strategic issues facing the healthcare organization, including change management, physician adoption, revenue cycle management and overall clinical transformation.

Issues in Oral Oncolytic Treatment

23 February 2010

COA Study Addresses Multi-faceted Issues Intrinsic in Oral Oncolytic Treatment

Oral oncolytics have been around for many years, now, and many more are in drug company pipelines.  Some of them are available in both oral and IV formulations, while others are only available in the oral form.  With oral oncolytic treatment set to escalate in usage, multiple issues must be addressed.  Community Oncology Alliance (COA), with the help of Avalere Health, has released a study, providing a thorough review of the respective issues and offering various solutions.  Chief among these issues are costs that affect both patients and providers, compliance and side-effect management.

Costs come in two different forms, both of which coming down to insurance reimbursement from both Medicare and private payers.  Essentially, patients are expected to shoulder a much higher percentage of the drug costs, as oral oncolytics fit into the highest tier prices of prescription oral medication.  And, losing already significantly reduced IV infusion reimbursements, poses a significant loss in revenue to medical oncologists.  As oncology offices provide multiple services that are not reimbursable, the ability to be reimbursed for IV infusion therapy helps to compensate for costs associated with those services.  Further complicating matters is the inclusion by Congress of some oral oncolytics in Medicare Part B, while others are only covered in Medicare Part D. 

Compliance and side-effect management are the other serious concerns.  The convenience of taking an oral oncolytic is certainly superior to in-office IV therapy.  On the flip side is the appropriate worry of patient non-compliance.  One key reason for non-compliance is side-effects.  When a patient is forced to come to an office for IV chemotherapy, the oncologist knows the patient has received appropriate treatment and can address side-effects as they surface rather than have to rely on the patient or caregiver’s communication of such.  If the patient experiences significant enough side-effects, there is always concern of drug discontinuation without alerting the physician or office.

COA’s study presents concerns from all sides of these and other issues including input from oncologists, nurses, insurance companies and patient groups, to name a few.  Taking all issues into consideration, the article concludes with best practices on how to compensate and adjust to the inevitable increase in oral oncolytic usage.  You can view the executive summary here from COA’s website:  http://www.communityoncology.org/wp-content/uploads/Avalere-COA-Oral-Oncolytics-Study-Summary-Report.pdf.