ASCO Town Hall Focuses on Utilization Management Concerns, Initiatives

06/02/18

On Saturday afternoon at the 2018 American Society of Clinical Oncology (ASCO) Annual Meeting (June 2, 2018; Chicago, IL), the ASCO town hall convened to share different perspectives on administrative burden, pharmacy benefit managers (PBMs), and clinical pathways.

The panel of presenters included Barbara L McAneny, MD, MACP, FASCO, president, American Medical Association (AMA); Melissa S Dillmon, MD, Harbin Clinic LLC; Blase N Polite, MD, MPA, FASCO, University of Chicago; and Robin Zon, MD, FACP, FASCO, Michiana Hematology Oncology, PC.

Dr McAneny began the discussion by sharing the AMA’s efforts regarding prior authorization. The AMA is working directly with national partners and payers to “right-size” prior authorization, she said, while asking state legislation to address prior authorization and step therapy and advocating to national policymaking organizations for regulation of these programs. Furthermore, the AMA is in the process of creating new resources to help practices streamline prior authorization.

As for prior authorization advocacy efforts in 2018, Dr McAneny listed a variety of research, state legislation, direct insurer engagement, practice education, and grassroots initiatives in which the AMA is involved.

Dr McAneny concluded her presentation by describing a new coding system the AMA is creating that takes into account social determinants of health. The system is designed to stratify prior-authorization patients and contribute significantly to more efficient, effective patient care.

Dr Dillmon spoke next on issues from the states in regard to PBMs. The concerns about PBMs are varied and well documented, she noted. She referenced a study from the American Cancer Society that found PBMs are regularly placing cancer drugs on the highest tier of their formularies as well as another from the Community Oncology Alliance that found PBMs have been pushing the dispensing of drugs away from physicians. The ASCO State Affiliate Council has identified PBMs as their highest policy priority for 2018, she added.

Among the state-level efforts to address PBM concerns are a variety of proposed legislation, including anti-mandatory mail order, anti-gag clauses, clawbacks and recoupments, fair pharmacy audit, non-medical switching, MAC list transparency, and other utilization management bills.

Dr Polite took to the podium next to share the federal perspective on the rising costs of cancer drugs. “Rising cost of drugs is a top priority for everybody,” he stated, referencing President Trump’s latest address in which reducing the price of prescription drugs was deemed a “top priority.” The administration has proposed a competitive acquisition program, transitioning drugs from Medicare Part B to Part D, and 340B reform. ASCO’s position on the matter, he added, is to hold physicians accountable for utilization of the drugs, rather than market entry pricing.

He then gave a review of ASCO’s 340B recommendations, which include improved transparency on use of funds, discontinuation of DSH as an eligibility criteria for hospitals, refinement of program definitions (including the word “patient”), funding to the Health Resources and Services Administration for oversight activities, emphasis on understanding adverse impacts 340B may have on patient access to high-quality cancer care, and consideration of how expansion affects patient access to care in the community setting.

“We can expect 340B legislation to be a hot and heavy topic in upcoming legislative sessions,” he concluded.

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Dr Zon spoke last about ASCO’s vision for clinical pathways as a utilization management resource tool. She noted previous concerns identified by the State Affiliate Council and Clinical Practice Committee, including administrative burden, patient autonomy and variability, lack of transparency among pathway developers, and implementation concerns. As a result, ASCO published the Criteria for High-Quality Clinical Pathways in Oncology in 2017 that detailed nine development, implementation, and analytics criteria.

The rationale behind clinical pathways is multifaceted, she continued, explaining that pathways help achieve a fair, adequate, and stable payment environment for oncology practices; ensure delivery of the right treatment for the right patient at the right time; and ensure the full range of services needed by patients with cancer is supported within a value-based reimbursement system that increases patient satisfaction and cost-savings. Additionally, pathways may provide an oncology-specific alternative to proposed methodologies for reimbursement and assessment of quality performance and resource use in the Quality Payment Program, she added.

Not only can high-quality clinical pathways be leveraged to measure resource use in MIPS, but they can also be utilized as a foundation for alternative payment models, Dr Zon noted. In her conclusion, she posed three questions to the audience: what are the “must have” characteristics necessary to use oncology-specific pathways for measurement of quality and cost, what data or evidence can be used to demonstrate to payers that using pathways to measure quality and cost is viable, and is there potential for practice uptake of these models by government or commercial payers?—Zachary Bessette