Why ICOP?

The challenges that community oncology has faced in recent years have inspired innovators to develop new platforms and ideas, many of which have been implemented with various degrees of success.

Struggling oncology practices, especially those squeezed by large hospital conglomerates, seem to have had no choice but to sell out; we can’t blame them; they were squeezed by powers that they could not resist or fight.

Smaller practices, on occasion, have joined larger ones to augment their purchasing power. This aggregation is good as long as practices can stay independent so that community oncology survives and succeeds.

Other practices have investigated large national aggregation models, many supported by investors, and they seem to be doing well. In these recent models, practices that join are required to sign contracts in which they lose all or part of their independence, though they do gain benefits in terms of volume-based contracting, management, and even potentially taking advantage of ancillary services and pharmacy benefits. This loss of destiny and control has made these platforms less appealing to many independent-minded practices. This has mandated a different model, one in which practices maintain 100% independence in everything, purchasing, management, staffing, billing, everything.

Realizing that no size fits all, specifically that none of the above scenarios fits many of the independent oncology practices, we at ICOP produced a model in 2020.

This is how it works.

Innovative Community Oncology Practices (ICOP) works through a different platform:

1. Practices keep doing exactly what they have been doing, with zero change.

2. ICOP contracts with pharma for rebates in addition to what they get from their respective GPO. This rebate considers all ICOP purchasing power as one entity, although each ICOP practice maintains its Tax ID, NPI, and others.

3. ICOP receives the additional rebate from pharma and redistributes those monies to ICOP members.

4. There is no joining fee.

5. Practices can join and exit at their will, no strings attached, NONE…

6. ICOP does not have a sales force to propagate our concept. Our members are our sales force, word of mouth, and this website, of course.

7. There is no minimum or cap on practice size to join ICOP.

8. Start up and enhance clinical research for ICOP sites via the affiliated Sargon Research Network.

9. Information sharing about best practices

10. Assisting ICOP affiliates when challenges arise.

There is no doubt that ICOP members have exceeded our own expectations in terms of pharma contracts. We are predicting a surge in the number of contracts in the coming few months. Our growth curve is healthy, and all members are excited.

Inflation

Current inflationary trends will affect every business sector of American society, some more than others. Although we do care about society at large, ICOP is focused on addressing the longevity and survival of independent community oncology, which has been compromised to a great extent in the last decade. These compromises, in the past and present, make community oncology more vulnerable to inflation. Therefore when the price of gasoline and bread rises, we, the owners of independent oncology practices, have to adjust the wages of our employees to offset these rising prices because we care about the well-being and financial livelihoods of our associates.

The cost of running a business is naturally affected by this inflation, not just the higher wages paid to employees. We have to pay extra for heating and cooling. We expect a rise in the cost of supplies needed to administer chemotherapy and other services. Ironically, we don't get paid for these supplies. Long ago, CMS and payers decided the cost of tubing, fluids administered, needles, port access devices, angiocaths, and many other things would be included in drug administration fees. We absorb that cost. Any additional increase in the cost of supplies is a net loss from our bottom line. I don't foresee a reversal of bundling fees: history has taught us a lesson- that payers keep lowering our reimbursements and rarely increase despite the normal annual increase in the cost of living.

In the current environment, the cost of living is trending toward a double-digit increase. In fact, we just learned that wholesale prices had gone up 9.6%. That increase is generally passed on to the consumer because the tail of the supply distribution chain will not absorb the increase in cost. Massive inflation is daunting to all of us and is already impacting independent community physicians, oncology practices in particular.

The most alarming observation to me is the labor shortage. The laws of supply and demand have come true to their scientific promise. We at community oncology have quickly adjusted to the labor shortage by raising wages for existing employees and for future hires, as we had no choice. But, again, without a substantial adjustment to our fee schedules, community oncology is in a bind.

We should not expect private payers to meet our needs voluntarily- they don't do that, and have not done that historically- but there is light at the end of the tunnel.

Most payers use a fee schedule based on CMS reimbursement rates. That means if CMS raises their fee schedule, payers should follow suit (if they honor their current contracting schedule) unless they decide to adjust their percentage of what CMS pays.

So far, the Government seems eager to give substantial raises to their employees as they target physician fees whenever a cut in health care spending is planned. So what should we do?

First, political activism is critical. We need to start calling our federal elected officials, educating them (a hard task) on the danger community oncology is facing. Second, as I have explained in the past, diversifying the scope of our services makes us less vulnerable to government actions and policies. Examples of diversified services are clearly outlined and implemented at our cancer center, including imaging services, on-site primary care clinics for medium and large-size employers, Covid mitigation services, and many other lines of services we share with our Sargon/ICOP Summit attendees. Thirdly, the only professional service community oncology can excel at without reliance on Government and payers is Clinical Research. We factually negotiate contracts in earnest and transparency. We accept trials that are economically viable and profitable to our practices. Sponsors of clinical trials want to attract well-performing sites and are willing and able to pay the prices needed and required. Moreover, sponsors do pay on time, with no preauthorization and no retroactive verification chart review, as payers and CMS often do, which sometimes requires us to pay back what we have earned legally and professionally.

Yes, clinical research is cumbersome, especially for the research virgin sites. But we have succeeded in overcoming those challenges through our Sargon Research Network, where we help practices start from scratch with the hope of intent that those affiliates will soon be as successful in research as Gabrail Cancer Center has been in the last two decades.

I know I have highlighted the negative side of inflation and its impact on the future of community oncology. Still, I am an optimist, zooming on solutions that I have outlined above to provide tangible long-term solutions to our everlasting unpredictable challenges. Unfortunately, those challenges are, for the most part, manufactured by the Government. But as President Ronald Reagan (the Great One) said, " Government is not the solution, it is the problem.”

Nashat Y Gabrail, MD

Gabrail Cancer and Research Center

The War on Small Businesses

Innovative Community Oncology Practices “ICOP” was established in 2021 as an association of small and medium-sized community oncology practices with the aim of promoting our survival in the face of mergers and acquisitions. Although we have no political agenda, policies in all their forms and shapes do affect our mission and survival. Hence addressing those political matters is at the core of the ICOP mission.

It is no secret that since the 1970s when Stark Laws were implemented, small community medical practices were the main target. The essence of Stark zooms on preventing independent practices from working together to their benefit and the benefit of the patients and society. As it stands now, several independent practices can’t collaborate in negotiating payment terms with payers and can’t collectively build an imaging center or any other commercial entity unless they merge in one group under one unified Tax I.D. number, which would compromise their cherished American way of independence. So why is it crucial for the policymakers to insist on this policy? Let’s talk about who is behind this.

The American Hospital Association saw the risk of physicians working together in competing with hospitals. Forming an imaging center, which would naturally provide more accessible and lower-cost services, would force hospitals to be more efficient at a lower and competitive cost. Hospitals enjoy a non-competitive atmosphere. Add to that the fact that hospitals realized that doctors, by nature and training, aim at the independence that allows them to be more efficient in providing services to patients in a timely fashion. They are a great example of the American way of innovation through an agile efficient business operation. Innovation flourishes when there is competition.

Policymakers generally align with the Dream of hospitals, even though large institutions are the essence of monopoly controlling the marketplace. To achieve that Dream, the hospitals, through their massive budget financed by their high cost of service and non-taxed status, can and do contribute large sums of money to political campaigns as active lobbyists. The alliance between politicians and hospitals has been to the detriment of small practices and on a larger scale to all small businesses. This became more obvious during the Covid pandemic, where large businesses were allowed by the government to stay open while small ones were forced by rules to close their doors. Many small businesses were forced out of the competitive environment while the Wal-Marts of the world not only stayed open, they flourished.

Despite mounting evidence that community oncology provides more accessible, better-personalized care at a much lower cost, there seems to be little or no effort by policymakers and even payers to take advantage of this crystal clear observation. Congress seems at all times eager to pass new laws, but they rarely, if ever, reverse or delete laws enacted centuries ago. Some of the laws contradict old ones, but no one seem to care to notice. If policymakers and the insurance industry are for better quality and lower cost, why is it that no one, none of them, has hinted to revisit Stark laws? As they say, “follow the money stupid.” At any political fundraiser, I have attended, and I have hosted and participated in dozens of them, there would be less than a handful of physicians, yet hospitals are represented by several with generous checks in their hands. Elected politicians are humans, they aspire to re-election over and over, and money seems to win most elections, local or national. Hospitals come with large checks, several from each. Doctors see patients hoping that the honest elected officials do their best to help patients and society.

In excess of 60% of community oncology practices have either closed their doors or been acquired by large hospitals and academic centers. Reversing that would be a challenge unless positive, meaningful measures are taken. Insurance companies, assuming they care about quality, access, and cost- that is a big assumption since payers profit on margin; the higher the cost, the larger their revenues- must change their payment system to equalize revenues for the same services wherever services are rendered (Payment Parity). Unless policymakers see the light and act, the future of community oncology and other specialties is in peril.

Is it good for the healthcare consumer to have rules whereby hospitals get paid higher fees for the same services that can be provided by independent practices? Is it because, as some insurance executives have said,” hospitals have higher overhead.” Isn’t that subsidizing and promoting inefficiency to the detriment of our patients?

Unless elected officials and policymakers see the light and act for the best interest of those who put them in power, independent medical practices are in jeopardy. The question is, how do we make elected officials do what is right? In the old days, elected members of Congress had jobs; they were farmers, merchants, active members of the armed forces. They spent three months a year in Washington DC enacting laws. Then they went home to make a living. Now being a politician is how they make money- and lots of it. It has become a business and an endless career. I might be hallucinating by suggesting that term limits are the answer so that elected officials do what is good for their constituents and the country, but that is an illusion. It is hard to imagine career politicians stripping themselves of laws that protect their professional life and deep pockets.

What is left of community oncology needs to coalesce as in what ICOP does, to be innovative and create a voice that is loud and clear. I have not lost hope, and we should not. Our task is not more difficult than that of Martin Luther King Jr., who had a dream that came true against all the odds. We can do it as community oncologists, and we can have the Dream. In America, nothing is impossible. It is the land of the free and innovation. Join Innovative Community Oncology by visiting www.innovative-oncology.com or email Carrie Smith, csmith@gabrailcancercenter.com.

Nash Gabrail MD

Gabrail Cancer Center