The Weapons of Getting Paid: Bringing Data, Technology, and Advocacy to the Battle

In recent years, advances in clinical oncology have been offset by administrative burdens: more requirements from Medicare, more quality improvement tasks from payers, and especially more proof that a patient needs a drug or test before reimbursement happens.

Speakers at the Association of Cancer Care Centers’ (ACCC) 51st Annual Meeting & Cancer Center Business Summit session, “Payer-Driven Challenges and Solutions,” reviewed strategies to deal with common complaints such as prior authorization and being shortchanged on contracts. And increasingly, oncologists and cancer center leaders are heading to their state legislatures for relief. Susanne Tameris, MHA, senior director of cancer services, Luminis Health, Anne Arundel Medical Center, DeCesaris Cancer Institute, served as moderator.

Bringing Data to the Payer Contract Battle

Providers must know every detail of payer contracts and come to contract talks armed with data to back up arguments, said Matt Mulherin, chief growth officer for AC3 Health.

“You have lots of data,” Mulherin said. “it’s how you pull it together. How do you harness that power and leverage it?”

Matt Mulherin | Image: LinkedIn

Gaining insights into Medicare data is relatively easy; for other payers, it’s challenging. Drug costs change for every payer every quarter, and timelines for when they change are variable. “If I want to be cynical, it's complicated by design,” Mulherin said. Constant change makes it harder for providers to keep track of what they should be paid, he said, and that makes it hard for them to hold payers accountable.

But providers must do the leg work necessary to hold payers to the terms of a contract. “You have to understand it, and it takes some time and some energy and some resources to do that, but you can't hold someone accountable to paying you correctly—which is an important piece of the accountability puzzle—if you don't know what you're supposed to be getting paid.”

Mulherin offered several key pieces of advice for revenue cycle managers:

• Use payer scorecards and key performance indicators (KPIs) to identify “problem payers,” and use these tools to negotiate better reimbursement rates based on underpayment or slow payment
• Understand which payers put more clinical burden on the staff.
• Using artificial intelligence (AI), or “payer contract intelligence” can speed identification of errors and development of performance metrics.
• Use benchmarking in setting fee schedules to improve financial performance.
• Make sure you are paid, and that you are paid correctly.
• Make sure data is accessible to the leadership, payer contracting, and revenue cycle teams, and that everyone knows how to use it.

Aligning the billing system and the practice management is essential, Mulherin said. Otherwise, it’s hard to know if you are paid reflects performance specifications that are in the contact. “There might be certain metrics that they have to adhere to, or that you have to adhere to,” he said, and revenue cycle managers must know and track KPIs that center on denials and time to pay.

What about value-based care? “I think there's lots of opportunities for us to innovate with payers,” Mulherin said. “But one thing that often gets overlooked is we're not really following well on a fee-for-service model.” It’s fine to have a value-based contract for some things, but that doesn’t mean the provider shouldn’t get paid on the portions of the contract that are still fee-for-service.

He encouraged those in attendance to keep track of who are the good actors. “Maybe nobody's paying you as fast as you want, but it's important to understand how is one payer doing compared to the rest of your payers and being able to see them side by side. It helps you to understand who's good , who's bad. Also, it does matter. We might not think that it does, but it does matter to a payer.”

It’s one thing to tell a payer they are one of the worst in terms of time to pay, but it’s another to have data to show their denial rate is 1.5 times higher than most payers, Mulherin said. “They don't have that data, and it's going to put them on the defensive, or at least it's going to establish that you have some credibility and some power in the relationship.”

Advocacy Makes a Difference in PBM Reform

When a patient makes it to the Texas Oncology clinic in Paris, Texas, Sucharu “Chris” Prakash, MD, who has been medical director almost 25 years, is determined that they be treated that day.

Sucharu "Chris" Prakash, MD | Image: Texas Oncology

Many have traveled long distances. “They are undergoing hardships; there are socioeconomic disparities,” said Prakash, who since 2022 has served as Texas Oncology’s director of quality services.

Having to jump through hoops with a pharmacy benefit manager (PBM), or what Prakash calls a “middleman,” doesn’t help. The Big 3—Express Scripts, Caremark, and Optum—control 80% of the market and not only negotiate prices, but they also dictate who gets to fill the prescription. So much so that pharmacies that served places like Paris, Texas, have closed all over rural America.

Bipartisan frustration with these practices and others has kept alive a Federal Trade Commission lawsuit against the 3 largest PBMs, despite the change in administration and the departure of former FTC Chair Lina Khan, JD. Republicans on the House Oversight Committee have been equally aggressive in calling for reforms. PBM reform is a top agenda item for both ACCC and for the Community Oncology Alliance (COA), which included it in the recent document, COA Prescription for Health Care Reform.

“The power of the top 3 PBMs—they hold all the cards,” Prakash said.

He described the cascade of issues that harm patients: PBMs restrict formularies, making it harder for patients to get certain cancer drugs. They charge patients too much for drugs, causing high out-of-pocket costs. They steer patients to affiliated pharmacies, even if these are mail-order outfits that cannot offer same-day service. Independent pharmacies are vanishing, crushed by high direct-and-indirect renumeration fees, or “claw backs” that the PBMs charge after a drug is dispensed. And until some states passed transparency laws, no one was sure where drug manufacturer rebates were ending up.

“What does utopia look like—if you were to solve all the problems, lower prescription drug costs for the patient, so the prescriptions cost less?” Prakash asked.

He outlined his own prescription for reform:

• increase transparency, including disclosing the use of manufacturer rebates;
• limit out-of-pocket costs; this would mean banning copay accumulators, which prevent copay assistance from counting toward out-of-pocket costs;
• end spread pricing, in which the PBM charges payers, including Medicaid, more than they pay the pharmacy for a medication—the PBM keeps the "spread.”

Then, Prakash offered a rundown of how advocacy efforts in Texas had curtailed many PBM practices.

• In 2017, Senate Bill (SB) 680 limited insurers’ use of step therapy, requiring protocols to be based on clinical evidence—not cost—and giving patients a faster appeals process. Also in 2017, SB 1076 passed, which barred health plans from overcharging for drugs at the point of sale.
• In 2021, which Prakash called a landmark year, Prakash said oncologists focused on business practices; Governor Greg Abbott signed 2 more measures: House Bill (HB) 1919, which bars PBMs from steering patients to affiliated pharmacies, and HB 1763, which ensures patient access to prescription drugs.
• Most recently, HB 1647, which took effect September 1, 2023, bars certain health plans from white bagging, in which patients with cancer or other complex conditions are forced to have drugs shipped to their physician from a central pharmacy for administration. Physicians said the practice leads to treatment delays and waste because if bloodwork in the clinic shows the need for change in dose, the shipped medication cannot be used.

Prakash elaborated on the importance of HB 1763, which he said bars PBMs from limiting the ability of pharmacies to deliver drugs to patients who live far away. If patients have the prescription, “they don't have them drive over and have the prescription in their hand, but you can do it deliver through the mail.”

He also highlighted the importance of eliminating step therapy. “Don’t tell me to treat the patient with ibrutinib first, if I want to do acalabrutinib” for certain blood cancers, he said. “The provider should be able to make that decision.”

The problem, Prakash said, is that Texas reforms do not apply to ERISA plans. Going forward, this could change. He highlighted a key case in Arkansas, “that was a precedent setting case, where basically the Supreme Court said that the policy should lie in the hands of the state, that if there's any PBM regulation passed that's in Texas, it should override ERISA plans or include ERISA plans.”

How a Centralized Prior Authorization Team Made a Difference

Orlando Health Care Institute (OHCI) created a centralize prior authorization team to boost the use of prospective prior authorizations (PAs), in which the use of AI tools and pharmacist involvement on the front end of the process decreased patient wait times for medications to an average of less than 48 hours, according to Andrea Ledford, PharmD, MBA, BCOP, BCSCP, FASHP, FHOPA, senior pharmacy director, Oncology Services at OHCI.

Ledford started her talk by outlining the purported goals of PAs: optimizing patient outcomes, reducing errors and waste, and reducing unnecessary drug costs. She cited several articles, from JAMA and ACCC’s own journal, which found oncologists say the opposite is true.

“What we've really found is it's actually a barrier to timely, quality healthcare. I think we would all agree with that the average length of time for a PA is about 2 to 5 days,” she said. At her own clinic, it was easy to walk through the clinic and see nurses on headshots doing PAs nonstop. Patients, physicians, and administrative staff are all frustrated.

What PA actually does, she said, is create “increased administrative burden in our clinics and an increase in patient anxiety as they're waiting for their life saving medications.”

Through a pilot project, OHCI decided to put the oncology pharmacy team in the mix on the front end. The pilot occurred just as Florida was making a policy change that would require additional PAs, which Ledford distinguished between retrospective and prospective PAs. The process is handled through an automated form built into the electronic medical record (EMR) platform, and the oncology pharmacist fills out answers to a host of required questions on the PA within 24 hours. Then the prescription is released to the pharmacy with the oncology pharmacist’s answers attached.

The shift required EMR training. “We used pharmacy technicians; we taught them where to look for the information in the EMR. We had to grant them more access so they could see the ICT 10 codes and the CPT codes and just where the physicians were documenting the relative relevant information that we needed to support the claim.

The change also required a structured process to create an online chat to eliminate calls to resolve questions and keep all communication within the EMR. “What found is we were able to leverage that EMR,” Ledford said. “We really spent time working on the workflow.”

At first, some of the nurses did not want to let go of the PA process. But later on, some PBMs required the pharmacy team to use their platforms, which Ledford would have created issues for the nurses alongside their other work. After a year, the process is being handled through 2 pharmacy full-time equivalent staff. The redeployment has vastly improved efficiency and patient experience, Ledford said.

“We looked at only the retrospective [PAs] because we weren't using any of the prospective before we started. We had lots of faxes and papers all over the clinics. Nursing was on the phone. We had delays for both patients in the clinics and patients waiting for authorization,” she said. “You couldn't room patients because people were stuck on the phone, and then patients were waiting in the rooms longer because people were on the phone.”

The pharmacy team initially handled 28 clinics; it’s now up to 36 clinics. “We've done to make it more attractive to the pharmacy techs, I have not had anybody turn over on the pharmacy tech team now in about 18 months, and what we do is we let them work remotely from home, so it's a good job for them.”

“The physicians, the clinic staff, they just loved it. You do have enhanced communication between the teams. And we're already started on our next step, which we're all tired of, the peer to peer in the appeals for all the targeted agents.

Ledford has met with payers and is developing a structured note based on successful peer-to-peer encounters, and clinical pharmacists will fulfill this role.

Most of all, patients are happier. “We did do the statistics on it, and it was statistically significant for our team.” The control group received 93.5% approval, while the group using the new system received 97.4% approval.