Oncology Reimbursement Past, Present and Future Association of Northern California Oncologists Medical Oncology Association of Southern CaliforniaSlide 2
Welcome & Introduction Peter Paul Yu, MD ANCO President Steven Tucker, MD MOASC PresidentSlide 3
Forthcoming ANCO Events • ANCO Audio Conference: Managed Care Contracting in an ASP World Wednesday, July thirteenth, 12PM • ANCO 2005 Annual Meeting Tenaya Lodge at Yosemite October 14-sixteenthSlide 4
Acknowledgment of Support Sponsors AMGEN • APP/Abraxis Oncology Bayer Oncology/Onyx Pharmaceuticals • Berlex Laboratories Genentech BioOncology International Oncology Network/Oncology Supply • MGI Pharma Millennium • Novartis Oncology Therapeutics Network/Onmark Exhibtors AstraZeneca • biogenIDEC • Bristol-Myers Squibb Oncology Celgene • Enzon Pharmaceuticals • Lilly Oncology National Oncology Alliance OrthoBiotech/Tibotec Therapeutics • OSI Pharmaceuticals Pfizer Oncology • Sanofi Aventis Oncology Schering-Plow Oncology • US OncologySlide 5
Oncology Reimbursement Past, Present and Future Dean Gesme MD FACP FACPE Past Chair , ASCO Clinical Practice Committee Past Chair, National Coalition for Cancer Survivorship Managing Partner, Iowa Cancer CareSlide 6
Do something consistently that panics you! Eleanor RooseveltSlide 7
Ground Rules All Theories aren\'t right yet some are helpful.Slide 8
Doctors are men who recommend drug of which they know pretty much nothing, to cure illnesses of which they know less, to person of which they don\'t know anything. Voltaire 1694-1778Slide 9
What Health Professionals and Patients Want Quality CareSlide 10
What Payers Want Cost ControlSlide 11
Value = Quality Price Value EquationSlide 12
Everywhere the old request changes, and upbeat are the individuals who can change with it Sir William OslerSlide 13
System Change Transactional TransformationalSlide 14
Transactional Change - incremental - arranged - political - forcedSlide 15
Transformational Change - adjusted worldview - move in qualities - change in convictionsSlide 16
Cost Control is Transactional Quality Improvement is TransformationalSlide 17
"Changed implies that when challenges are out of hand, we put more in quality" Charles Buck – resigned GE officialSlide 18
Transformational Change Process Vision Strategy Trust Tactics Tests/Trials ImplementationSlide 19
Physicians and Trust Only the best and brightest are picked Thus, you are the best Others may not be as great Thus, others may commit errors You will be in charge of all slip-ups influencing your patients Therefore, others can not be trusted Teams incorporate others and in this way can not be put stock inSlide 20
Transformational Change Vision Strategy Trust Tactics Tests/Trials ImplementationSlide 21
What We Say We Want Patient-driven nurture Performance Improved Quality Improved OutcomesSlide 22
What We Will Pay For Process-driven tend to methodology Piecework mindset Identical Pay for Best or Worst CareSlide 23
All speculations aren\'t right yet some are helpfulSlide 24
Oncology Reimbursement History Current Situation Future PossibilitiesSlide 25
History Surgery -1809 first elective surgery -1867 antisepsis - Lister -1890 Halsted radical mastectomy -1896 oophorectomy for bosom malignancy -1913 American Society for Control of Cancer -1936 Women\'s Field Army -1945 American Cancer Society establishedSlide 26
"There must be a last cutoff to the advancement of manipulative surgery, the blade can\'t generally have crisp fields for triumph and in spite of the fact that techniques for practice might be altered and differed and even enhanced to some degree, it must be inside a specific breaking point. That this point of confinement has about, if not exactly, been come to will seem obvious on the off chance that we ponder the immense accomplishments of present day agent surgery. Next to no remaining parts for the boldest to create or the most adroit to perform." Sir John Erichsen Lancet 1873Slide 27
Surgery Endoscopies Laparoscopies Sentinel hub assessments Stereotactic strategies Enhanced diagnostics – CT, MRI, PET, Ultrasound RFA, cryoablative systems Nanotechnologies TransplantationSlide 28
Radiation Therapy 3D modernized treatment arranging IMRT Dynamic dosage conveyance methods Continuous RT Stereotactic Radiosurgery Intracavitary brachytherapies RadioimmunoconjugatesSlide 29
Pay Per Procedure New techniques evaluated generously Procedure turns out to be faster, more secure, and less complex with time Eventually, commoditization happens and value falls Procedure supplanted by new innovation and again estimated generously at firstSlide 30
Chemotherapy Reimbursement HISTORY -1946 Nitrogen mustard -1953 Aminopterin -1960s alkylators and anti-toxins -1970s platinum mixes, BMTs -1980s taxanes, biotherapies, ABMT -1990s development components, hostile to emetics -2000 focused on treatmentsSlide 31
Drug Reimbursement 60s through mid 80s – inpatient mind – cost in addition to evaluating 80s-2005 – AWP estimating strategy - advancement to outpatient mind setting because of: -enhanced against emetic regimens -shorter medication mixtures -accessibility of gifted oncology attendants -doctor interest in foundationSlide 32
Office Based Chemotherapy 81.3% to 85.7% of chemotherapy given in office setting in 1990s as per National Centers for Health Statistics (CDC) Patient inclination much of the time 98% office based chemotherapy in many practices Skilled staff, particular officesSlide 33
Drug Reimbursement AWP evaluating -basic, distributed reference -reproducible and irrefutable -subject to control leucovorin, lupron, generics -disputable -unsustainableSlide 34
Oral Drugs Levamisole - cheap veterinary hostile to helminthic item, repriced forcefully for adjuvant colorectal treatment. Thalidomide - restricted in the 1960s. Utilized for ENL in 1980s. Adjusted and repriced in 2000. Gleevec, Iressa, TarcevaSlide 35
ASP Methodology Untested Fairness subject to question Price to some will go up in the event that it goes down to others Average cost not accessible to all Congressionally ordered Unsustainable Some vibe the consequence of ASP will be accepted medication cost controlSlide 36
Drug Administration CMS utilizes AMA CPT coding for repaying all doctor administrations Administration charges in light of recorded charges and "practice cost" before 2005 as no "doctor work" considered Practice cost characterized utilizing "best down" procedure - normal cost every hour for every claim to fame as opposed to asset basedSlide 37
Drug Administration Drug organization relative qualities supplemented in 2004 by 32% extra commanded by MMA ASCO and different reviews recommend that organization costs still seriously underestimated even with the extra in 2004 2005 extra reductions to 3% Temporary codes for Medicare justSlide 38
Temporary Codes New code for embedded port flush – minor impact monetarily Add doctor work part to administrator codes – AMA RUC tosses out doctor overview information and utilizations bring down qualities like 2004 Unbundling of administrator codes for 2005 – yet hone cost recalculated to figure unbundling CMS orders installments for doctor time went through managing chemotherapy administrator difficulties – however no new codes and no thought of extraordinary assets Treatment arranging and administrations gave in respect to chemo administrator (quiet instructing, telephone calls, money related guiding, psychosocial bolster) not independently payable – AMA CPT Workgroup shapedSlide 39
Temporary Codes 2005 impermanent codes will be joined in AMA distributed codes in 2006 Thus, 2005 will see private arrangements utilize distinctive codes than Medicare Confusing and confounded for patients, doctors and payers Increased office overhead to billSlide 40
Americans dependably attempt to make the best choice, after they have attempted everything else. Winston ChurchillSlide 41
Demonstration Project Patient-driven Symptom administration – nature of care Fatigue, torment, queasiness – basic scale with insignificant documentation prerequisites $130/understanding/day for Medicare patients accepting parenteral medications in office Economically will reestablish 30% – 60% of general lessening from 2004Slide 42
MMA Changes for 2006 Where will ASPs "arrive"? Relapse to the mean anticipated at medication costs 3% chemo organization add-on is wiped out Competitive Acquisition Plan (MVI) – elective for practices, points of interest unverifiable All medications? Strong care drugs? Wellbeing Timeliness Drug disavowals Collection issues Costs of organization for practicesSlide 43
The ethical trial of government is the manner by which it treats the individuals who are in the beginning of life, the kids, the individuals who are in the dusk of life, the elderly, and the individuals who are in the shadows of life – the wiped out, the destitute and the disabled. Hubert H. HumphreySlide 44
The FutureSlide 45
It\'s hard to make expectations, particularly about what\'s to come. Y Berra, C Stengel, S Goldwyn, D Quayle, W Rogers, M Twain, V Gorge, G Marx, W Allen, and numerous othersSlide 46
The Future Transactional change OR Transformational changeSlide 47
Transactional Change Increase effectiveness - CMS\' suggestion to doctors IT/EMR – enhanced productivity and capacity to accumulate quality information, BUT who will pay for it – esteem condition does not support this Physician reaction – play by AMA/CMS rules ADD PROCEDURES CT, MRI, PET, Labs, every day or week by week chemotherapy Change understanding blend – decrease impoverished care, diminish Medicare presentation, allude inadequately repaid cases to healing centersSlide 48
When elephants move, the chickens must be watchful. Asian maximSlide 49
Transformational Change Physicians paid for restorative exhortation and care administrations Reasonable and impartial p
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