ONCAlert | 2018 ASCO Annual Meeting

Let's Rebuild 340B as a Patient-Centric Model, ACCC Executive Director Recommends

Shannon Connelly
Published Online: 9:04 PM, Fri April 28, 2017
This year marks 25 years since the federal government created the 340B Drug Discount Program, and now is the time to revisit how well the program is working for patients, says Association of Community Cancer Centers (ACCC) executive director Christian G. Downs, JD, MHA.
 
In an interview with Targeted Oncology during the 2017 Community Oncology Alliance (COA) annual meeting, Downs discussed his thoughts on how rebuilding the 340B program should be addressed, Medicare Payment Advisory Commission’s (MedPAC) Part B cost control proposals, and the potential for progress in tackling rising drug costs.
 
TARGETED ONCOLOGY:   340B has created its own ecosystem of dependence for healthcare programs. Do you anticipate that there will be constructive reform in 2017 or 2018?
 
Downs: I think “constructive” reform is the operative word. It's the 25th anniversary of the program, it's time to take a look at it to see if it's really functioning for patients, and then build it up as a patient-centric model. And there are a couple of things I think could be done with that. You can qualify patients for 340B, that way they are able to go to whatever location they need to go to. But then we also need to look at those places that are treating a high number of [people who are] underinsured, and say, instead of the 340B program as a means of covering some of that cost, what are some other things we can do so that patients in those situations and providers treating those patients are able to continue to do that? There's an opportunity right now to be able to do something. I think from a legislative standpoint, if we don't have a multi-stakeholder bill—1 where everyone sat down and got together and said this is what works for us, this doesn't work for us, come up with some compromise—then we'll have legislation, but I'm not sure if it's going to go anywhere. And that's on both sides. If you're going to have something that paces, something that's actually good, then you are going to need to have multiple stakeholders involved. 
 
TARGETED ONCOLOGY:  How does the ACCC view the MedPAC proposals for Part B cost control, particularly the proposed third-party vendor price negotiations?
 
Downs: ACCC has viewed these issues for probably 20 years. The big challenge with some of the MedPAC recommendations is they only look at 1 side of the equation, which is the cost of acquiring the drug. What they don't really look at in their proposals is the cost of giving the drug. I think that's where we need to focus. You can talk about reducing drug reimbursements, but then you also have to talk about covering the cost of the other services that are provided. If you're going to do that, it needs to be more of a bilateral discussion, particularly on the vendor program. That model particularly is probably not workable in the way the community setting is set up now for multiple different reasons.
 
I think people are open to multiple different methods of acquiring drugs, but they have to be slow, it has to be piloted, we have to see what works. That goes back to my point about the infrastructure that exists. We have a fragile cancer delivery infrastructure, from a financial standpoint. We need more providers. We don't usually do good when we have hammers coming down. It's much better to be precision oriented and say if we're going to do something like this, we're going to do it small, we're going to study it, we're going to learn how it works, make the changes, and then roll it out gradually.
 
TARGETED ONCOLOGY:  Trump has expressed interest in tackling rising prescription drug costs. Does that make the ACCC feel confident that there will be some new initiatives this coming year?
 
Downs: I thought 1 of his lines was interesting: "Who knew health reform was so difficult?" I think that same thing is going to happen with drug pricing. It is a complicated issue. It's a simple answer to say we should let Medicare go and negotiate prices, but you have to actually look at not only the legal challenges, but also some of the economic challenges that exist with it. It's not a perfect system right now. I think the underlying issue we need to make sure happens, though, is that whatever innovation we have is protected. I think in the long run that is going to be what we are really going to have to stay focused on.
 
Targeted Oncology: We have heard a lot about efforts to secure our borders. Will this have any impact on the oncology profession? 
 
Downs: I think that is 1 of the things that is not understood. The oncology workforce in this country is undermanned—and that's not just physicians, it's nurses, pharmacists, and social workers, so we need to be able to broaden that workforce. Demand is only going to grow. Not only in clinical complexity, but in sheer volume and numbers. We need to make sure we can bring in the good people who can help us, but then we are also developing people here in the country that are going to be the next generation of researchers, clinicians, nurses, and social workers. That's going to be an issue, and I think it's something we're going to need to keep an eye on because we're going to need more people. We have to bring good people in, and we have to bring good people up.
 
 
TARGETED ONCOLOGY:  What have we learned in our first year with the Oncology Care Model (OCM) that we can carry forward? Is this a model that is workable? 
 
Downs: The OCM is interesting. If you step back for a moment, you realize the enormity of the task. Not only from a provider standpoint, but also from the Center for Medicare and Medicaid Innovation’s standpoint. They have spent a lot of time and energy on getting this thing right. The greatest analogy is that they are building it as they are flying. That's a very tough thing to do. The amount of work and effort that providers are putting into this is really something to take a step back and look at. Only from a realism standpoint. This isn't something you can just decide to do on a whim—oh, we're going to go ahead and participate in OCM, or frankly, any alternative payment model for that matter. It's going to have to buy into the entire organization that if we're going to do this. We know this is going to be a big resource drain on us, it's going to be a lot of work on us, but at the end of the day, we're hoping we are going to improve patient care.
 
TARGETED ONCOLOGY:  Can you discuss the OCM collaborative the ACCC has created?
 
Downs: One of the things that ACCC has initiated is our OCM collaborative, where we are pulling together and looking at issues around the OCM. One of the big things we are looking at is what it costs to actually do something with OCM. That is going to be a big step because we're not looking for it to be something that is used by policymakers necessarily to say whether it's a good or bad idea, but really something that can be used within organizations to be able to say, do we want to make this commitment, and if we are going to make this commitment, this is what it's going to cost us.
 
TARGETED ONCOLOGY:  We have a number of practices that have closed their doors since 2008. I think COA has estimated that it is approximately 360 practices. Is this a healthy market process of supply and demand, or something we should be concerned about?
 
Downs: That is a big and tough issue. We are seeing consolidation across all health specialties, frankly, and for a lot of different reasons. Some of those are economic, some of those are legal, and some of those are policy-oriented. If you look at what we are seeing with some of the things in the ACA, those are all consolidation-heavy initiatives. The thing you want to be concerned about is people leaving the field, meaning if I have a physician who is in private practice and they shut their doors and go away, they walk off the field. We have too many patients coming in who are going to need services. We need to make sure we are keeping the players on the field, and looking at why some of these things are happening. Some of it is 340B, but a lot of it has to do with the regulatory burden that is happening to them, the fact that they have to do electronic medical records, the headache they have to deal with in the day-to-day business operations. So, what can we do to make that easier? If they want to join a private practice, they can, and if they want to join a hospital, they can, and they don't feel bad about that.

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