This report presents the American Society of Clinical Oncology’s (ASCO’s) evaluation of the adaptations in care delivery, research operations, and regulatory oversight made in response to the coronavirus pandemic and presents recommendations for moving forward as the pandemic recedes. ASCO organized its recommendations for clinical research around five goals to ensure lessons learned from the COVID-19 experience are used to craft a more equitable, accessible, and efficient clinical research system that protects patient safety, ensures scientific integrity, and maintains data quality. The specific goals are: (1) ensure that clinical research is accessible, affordable, and equitable; (2) design more pragmatic and efficient clinical trials; (3) minimize administrative and regulatory burdens on research sites; (4) recruit, retain, and support a well-trained clinical research workforce; and (5) promote appropriate oversight and review of clinical trial conduct and results. Similarly, ASCO also organized its recommendations regarding cancer care delivery around five goals: (1) promote and protect equitable access to high-quality cancer care; (2) support safe delivery of high-quality cancer care; (3) advance policies to ensure oncology providers have sufficient resources to provide high-quality patient care; (4) recognize and address threats to clinician, provider, and patient well-being; and (5) improve patient access to high-quality cancer care via telemedicine. ASCO will work at all levels to advance the recommendations made in this report.
Purpose: The purpose of the Oncology Care Model (OCM) is to improve quality and reduce cost through practice transformation. A foundational tenant is to reduce avoidable emergency room (ER) visits and hospitalizations. In anticipation of being an OCM participant, we instituted a multidimensional campaign designed to meet these objectives. Methods: Prior actions included establishment of phone triage unit, after-hours and weekend calls, and institution of weekend urgent care. Results: On the basis of data from the Chronic Condition Warehouse, as provided by the Centers for Medicare and Medicaid Services, we were successful at reducing the acute care admissions rate by 16%. During the baseline period extending from Jan 2016-Mar 2016, the hospital admission rate was 27 per patient, per quarter, at an average cost per admission event of $11,122, translating to an inpatient cost per patient, per quarter, of $3,003. In the year one reporting period of July 2016-July 2017, the hospital admission rate declined to 22.6 per patient, per quarter, at an average cost per admission event of $11,106, translating to an inpatient cost per patient, per quarter, of $2,505. OCM patient survey scores improved. In addition, at Oncology Hematology Care, we achieved improved results compared with the risk-adjusted national averages for the following measures: readmissions (4.9 v 5.6 per 100 patients, respectively), ER use (17 v 18.6 per 100 patients, respectively), and observation stays (2.7 v 3.6 per 100 patients, respectively). Conclusion: By implementing a cost-efficient, reproducible, and scalable campaign targeting ER avoidance and hospitalizations, we were able to decrease hospital admissions. Reported Medicare savings amounted to nearly $798,000 in inpatient cost per quarter over 1,600 patients.
The past decade has seen considerable innovation in the delivery of care and payment in oncology. Key initiatives have included the development of oncology medical home care delivery standards, the Medicare Oncology Care Model, and multiple commercial payer initiatives. Looking forward, our next challenge is to reflect on lessons learned from these limited-scale demonstration projects and work toward models that are scalable and sustainable and reflect true collaboration between payers and providers sharing common objectives and methods to advance cancer care delivery. To this end, ASCO continues its work on care delivery standards, quality measurement, and alternative payment models. Over the past year, ASCO has received input from physicians, administrators, payers, and employers to update its Patient-Centered Oncology Payment (PCOP) model. PCOP incorporates current work on provider-payer collaboration, the oncology medical home, and the value of clinical pathways and recognizes the need for common quality measurement, performance methodology, and payment structure across multiple sources of payment. The following represents a summary of the entire model. The model includes chapters on PCOP communities, clinical practice transformation, payment methodology, consolidated payments for oncology care, performance methodology, and implementation considerations. In future work, ASCO will continue its support of the PCOP model, including further development of care delivery standards, quality measures, and technology solutions (eg, CancerLinQ).
77 Background: In recent years, several antineoplastic biosimilar products have been approved and marketed for use. We analyzed data from the ASCO PracticeNET learning network to gain insights on the adoption of biosimilar products for bevacizumab, rituximab, and trastuzumab. Methods: Our analysis included the following products: bevacizumab, bevacizumab-awwb, bevacizumab-bvzr, rituximab (excluding rituximab and hyaluronidase), rituximab-abbs, trastuzumab, trastuzumab-anns, and trastuzumab-dkst, administered from July 2019 to March 2020. 19 practices submitted their billing data; practices ranged in size from 2 to 29 hematologists/oncologists. Products were identified through use of healthcare common procedure coding system codes. The proportion of biosimilar product doses administered, as a percent of total doses for all related products, was calculated per participating practice. Results: Use of biosimilar products for bevacizumab (first biosimilar approval in September 2017) was first detected in August 2019, averaging 1.4% of administered doses (confidence intervals included in Table) with a range from 0% to 27% among participating practices; by March 2020, average use increased to 31% with a range from 0% to 100%. Use of biosimilar products for rituximab (first biosimilar approval in November 2018), was first detected in January 2020, averaging 2.6% of administered doses, with range of 0% to 30%; by March 2020, average use increased to 18%, with a range of 0% to 61%. Use of biosimilar products for trastuzumab (first biosimilar approval in December 2017) was first detected in September 2019, averaging 0.9% of administered doses with a range of 0% to 17%; by March 2020, average use increased to 35%, with a range of 0% to 98%. Conclusions: The release of biosimilar products has been identified as a potential opportunity to lower the cost of drug therapy for cancer patients. Our analysis identified an approximate 2-year lag from product approval to initial utilization followed by a steady increase in the use of biosimilar products, along with a wide range of use among practices. [Table: see text]
30 Background: The purpose of the Oncology Care Model is to improve quality and reduce cost through practice transformation. A foundational tenant is to reduce avoidable ER visits and hospitalizations. In anticipation of being an OCM participant, we instituted a multidimensional campaign designed to meet these objectives. Methods: Prior Actions: Established phone triage unit. After-hours and weekend call. Instituted weekend urgent care. Year One: Improved education provided by nurse navigators and APPs prior to start of treatment (OCM Treatment Planning visit). Implemented triage pathways: 38 symptom and 27 follow-up pathways (modified COME HOME, Barbara McAneny, M.D.). Proactive symptoms follow-up calls to help circumvent emergent admissions. Increased APP staffing to provide blocked time slots for same day patient visits w/o schedule disruptions. Initiated “Call Us Early – Call Us First” campaign. Incorporated verbal and/or written instructions at all patient touch points, emphasizing patient’s responsibility to call before going to the emergency room. Results: Based on data from the Chronic Condition Warehouse, as provided by CMS, we were successful at reducing the acute care admissions rate by 16 percent. Conclusions: By implementing a cost efficient, reproducible, and scalable campaign targeting ER avoidance and hospitalizations, we were able to decrease hospital admissions. Reported Medicare savings amounted to nearly $798,000 in inpatient cost per quarter over 1,600 patients.[Table: see text]
Introduction: In response to the need for social distancing and infection prevention during the COVID-19 pandemic, there has been increased use of telehealth services to manage cancer and hematology patients. Throughout March and April of 2020, the Medicare and Medicaid programs expanded coverage of telehealth services, allowing cancer and hematology patients to receive certain telehealth services from their home during the public health emergency. We analyzed data from ASCO’s PracticeNET learning network to examine the reported level-of-service for telehealth services compared to standard in-office visits. Methods: 20 practices submitted their billing data for analysis; practices were located in 14 states and ranged in size from 2 to 29 hematologists/oncologists. We analyzed a total of 33,435 established patient evaluation and management visits performed by hematologists/oncologists from March 15 to April 18, 2020. 3,062 (9.1%) visits were performed via telehealth and 30,373 were performed in a physician office or outpatient hospital department. The level-of-service of each visit was identified through the reported Current Procedure Terminology (CPT) code, where levels 1-5 correspond to CPT codes 99211-99215, respectively, and level 5 represents the highest complexity visit. Telehealth visits were identified through use of the modifiers 95, GQ, and GT, as appended to the applicable CPT code. Results: The level-of-service distribution for telehealth-based visits was level 1 (1%), level 2 (4%), level 3 (35%), level 4 (50%), and level 5 (11%). This contrasted with in-office visits: level 1 (3%), level 2 (2%), level 3 (27%), level 4 (51%), and level 5 (18%). Differences were greatest in level 3 visits (35% vs. 27%) and level 5 visits (11% vs. 18%). Differences in level-of-service persisted when exploring various disease cohorts, including patients with solid neoplasms, blood neoplasms, benign hematology disorders, and circulatory disorders. Conclusions: Analysis of established patient visits showed that telehealth visits were reported at lower level-of-service as compared to in-office visits. This finding may be related to directing straightforward visits to be performed via telehealth or due to limitations in using telehealth by patients with complex medical problems. Citation Format: Brian Bourbeau, Mou Guharoy, Stephen Grubbs, Elizabeth Garrett-Mayer, Kevin Olson, Richard L. Schilsky. Differences in level-of-service for telehealth visits as compared to in-office visits for cancer and hematology patients seen in practices within the ASCO PracticeNET learning network [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-015.
Background: In April 2020, ASCO initiated a registry to capture and analyze status and outcomes of patients with cancer and COVID-19, and to describe effects of the pandemic on U.S. cancer practices. Initial findings of changes to care delivery are included. Methods: Practices provide data on changes to care delivery due to COVID-19 and longitudinal data on patients with cancer and confirmed COVID-19. At present, 26 cancer practices have enrolled in the Registry—5 academic, 15 hospital/health-system (H/HS) owned, and 6 physician-owned (P-O) located in 19 states. Enrollment of practices and data collection is ongoing. Results: Twenty sites, from 17 practices (3 academic, 9 H/HS owned, and 5 P-O in 15 states) responded (April 20-June 4). All incorporated telemedicine visits; 90% reported use of telemedicine was new. 30% reported “declining some but not all” new patient requests. For patients with cancer not on active therapy, 15% of sites postponed some routine visits, 35% conducted virtually all routine visits by telemedicine, and 50% used telemedicine for some routine visits. Most sites (95%) reported following clinical guidelines for visit postponement; 90% reported following local health authorities on when to resume routine visits. 90% screened patients prior to in-office visits for COVID-19 symptoms by phone and at clinic entrance; 10% screened patients using only one method. 30% modified intravenous (IV) drug infusions, including halting some or all (10%), shortening some or all (20%), or switching from IV to oral drugs (15%). While no sites conducted home-based, anticancer drug infusions, 30% are considering this option if COVID19 conditions change. Most sites modified laboratory specimen collection, including allowing a collection site closer to home (60%) and collection in a patient’s home (1 site). Two sites only allowed patients on oral anticancer drugs to use alternate collection sites. Only 1 site reported specimen collection in patients’ homes. All reported making the following changes to clinic arrangements: requiring use of masks, eliminating accompaniment by a support person (with exceptions), and reducing the visit numbers or increasing time between visits. No sites reported shortages of anticancer or supportive care drugs. 45% experienced shortages of nasopharyngeal swabs, 45% of medical hand sanitizer, and 75% of personal protective equipment. 40% of sites have experienced staffing reductions or changes due to reduced patient visits (30%), transfer to other clinical areas (20%), availability (15%), and COVID-19 illness (15%). Conclusions: The COVID-19 pandemic has had a substantial impact on most aspects of cancer care delivery in U.S. oncology practices. All practices incorporated telemedicine, which is new to most. Adjustments were made to patient visits and scheduled IV drug infusions. Sites reported shortages of equipment related to COVID-19, not cancer or supportive care drug shortages. At the time of the AACR meeting we expect to have data from more practices. Citation Format: Suanna S. Bruinooge, Elizabeth Garrett-Mayer, Stephen Meersman, Patricia Hurley, Brian Bourbeau, Allyn Moushey, Sybil Green, Deborah Kamin, Stephen Grubbs, Richard L. Schilsky. Changes implemented by U.S. oncology practices in response to COVID-19 pandemic: Initial report from the ASCO Registry on COVID-19 and cancer [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr S06-01.
PURPOSE Biosimilars offer increased patient choice and potential cost-savings, compared with originator biologics. We studied 3 years of prescribed biologics among US physician practices to determine the relationship of practice type and payment source to oncology biosimilar use. METHODS We acquired biologic utilization data from 38 practices participating in PracticeNET. We focused on six biologics (bevacizumab, epoetin alfa, filgrastim, pegfilgrastim, rituximab, and trastuzumab) for the period from 2019 to 2021. We complemented our quantitative analysis with a survey of PracticeNET participants (prescribers and practice leaders) to reveal potential motivators and barriers to biosimilar use. We implemented logistic regression to evaluate the biosimilar use for each biologic, with covariates including time, practice type, and payment source, and accounted for clusters of practices. RESULTS Use of biosimilars increased over the 3-year period, reaching between 51% and 80% of administered doses by the fourth quarter of 2021, depending on the biologic. Biosimilar use varied by practice, with independent physician practices having higher use of biosimilars for epoetin alfa, filgrastim, rituximab, and trastuzumab. Compared with commercial health plans, Medicaid plans had lower biosimilar use for four biologics; traditional Medicare had lower use for five biologics. The average cost per dose decreased between 24% and 41%, dependent on the biologic. CONCLUSION Biosimilars have, through increased use, lowered the average cost per dose of the studied biologics. Biosimilar use differed by originator biologic, practice type, and payment source. There remains further opportunity for increases in biosimilar use among certain practices and payers.
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