Download PDF of the article

You may have heard the maxim "all politics is local." It maintains that a politician’s continued success relies on how well he understands—and accommodates—what really matters to his constituents back home.

When a person has cancer, every single activity related to his care matters a lot—especially to him. Each action taken by anyone who participates in a planning process, touches a patient, enters information into a bill or schedules an appointment contributes to the overall success or failure. Unfortunately, actions taken by others can result in unintended consequences.

CMS and other carriers may have some rules that drive the folks who care for cancer patients crazy. An often-seen case is one in which a drug is billed differently than the dose given due to packaging and rounding. One example is Herceptin. The OIG RAC audit in 2012 stated, &If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit based on the HCPCS long descriptor to report the dose." Some well-intentioned pharmacists or nurses believe that charging for something they do not give is wrong and may be fraud. So they round down instead of rounding up to a unit that they didn’t give. But for some drugs, including Herceptin, this rounding could result in significant dollars being thrown away. For a busy practice or cancer program, those amounts could add up to tens of thousands of dollars.

Let’s consider a hypothetical scenario. The most recognized breast imaging center in a region prides itself on meeting guidelines, caring for patients and accommodating rapid appointments. A doctor calls in for an urgent diagnostic mammogram for his or her patient, who has presented with a large breast mass a few months after a normal screening mammogram was performed at that breast center. The new clerk, not seeing anything readily available and not wanting to cause the staff to work overtime one day, schedules the appointment for the next opening — in two weeks. The patient and referring physician are upset and choose to go to the competition. The patient is subsequently diagnosed with breast cancer and wonders how anyone could have asked her to wait two weeks to find it out when her doctor considered a follow-up quite critical. The patient is quite verbal about the inconsiderate care she received and the great reputation of the breast center is tarnished.

Here’s another hypothetical. A hospital is interested in recruiting medical oncologists and building a new cancer center, moving radiation oncology and having a comprehensive cancer center program. A business plan is developed with one scenario and set of assumptions but a major assumption does not stand up. For example, planners assume that the hospital will be able to apply for and receive 340b pricing but cannot comply with the rules. Or the hospital does not foresee the fight for the CON and delay in approval. To avoid being derailed by unforeseen roadblocks, planners must develop various scenarios that consider all possibilities and the impact on the program.

And here’s one more. A hospital is expanding its thoracic oncology program and recruits a very respected surgeon from another state. The contract is signed and the surgeon moves to the community, pending licensure in the new state. Although licensed in other states in the U.S., this state refuses to license him because he’s a graduate of an international medical school. The new state requires another year of residency for him to be licensed. A discussion with the state medical board could have resolved this issue prior to the move, but the lack of due diligence caused the program to be delayed for a significant time period.

As cancer program directors plan and manage their programs, their vision is typically directed toward broader issues, large growth opportunities and ways to improve care. But remember: all politics is local, and focused attention must be paid to the details. The weakest link can affect the best plans. All people at all levels—in any department—must be part of the planning, education and training for their role and fully aware of the impact each and every action has on the success of the program.

When developing large plans, make sure that everyone who can affect the success of that plan is part of the team. Listen to the naysayers, consider all options and outcomes. Make no assumptions that are not fully vetted. Examine every possibility to avoid surprises.

Ongoing programs need attention and maintenance. Continuous auditing, review and education are essential so that everyone on staff is mindful of the importance of his or her role and decisions. Don’t let complacency, cutting corners or simple ignorance of new rules creep into your everyday operations.

Plotting out various scenarios and the ways they might affect your program requires an understanding of all aspects of your program. The consultants at The Oncology Group bring that breadth of knowledge and experience, from clinical to financial, operations to technology. Let us help guide your program to surefire success. For more information, please call us at 512.583.8815 or email us at [email protected].