Site of Care Matters: The Value of Community Oncology The Payer Value Proposition September 2012...

Site of Care Matters: The Value of Community OncologyThe Payer Value Proposition

September 2012

Prepared for ION Solutions

2AmerisourceBergen Consulting Services – Confidential

Outline

Changing Oncology Landscape

Community vs Hospital-based Oncology Care

Current State of Oncology Management


The Value of Community Oncology

Patients managed in an office-based setting are less costly than those managed in hospital outpatient settings

Care provided in a community office-based setting is more accessible and less costly for patients

Patients in community settings utilize more generics and less brand therapies, which results in savings for payers

Community practices are more willing to participate in pay-for-quality pathway programs, which will translate into improved outcomes and savings for payers

Current State of Oncology Management


Consolidation in the cancer care landscape continues as larger hospital groups acquire, purchase, or merge with private, community-based practices

1. Practice Impact Report. Community Oncology Alliance. April 4, 2012. http://www.communityoncology.org/pdfs/community-oncology-practice-impact-report.pdf Accessed August 23, 2012

241 Clinics Closed

442 Practices Struggling Financially

47 Practices Sending Patients Elsewhere

392 Hospital Agreement/Purchase

132 Merged/Acquired by Another Entity

Changing Business Structure of 1,254 Oncology Clinics/Practices From 2008–20121

http://www.communityoncology.org/pdfs/community-oncology-practice-impact-report.pdf


54%

22%

13%

11%

Future (N=106 practices)

For the foreseeable futureFor at least 5 yearsFor another year or so onlyWe are changing now

In 2011, nearly 1 in 4 practices (24%) indicated that they are currently changing their business structure or may only remain viable for another year or so

1. Barr TR, Towle EL. National Oncology Practice Benchmark, 2011 Report on 2010 Data. J Onc Pract. 2011;7(6S):67S-82S.

How long to you expect this business structure will remain unchanged and viable?

24%

86%

10%

3% 1%

Current (N=106 practices)1

Physician-owned practiceHospital-owned practiceOtherAcademic practice


Payers’ Understanding of the Issue

• Payers understand that oncology is unique and must be approached differently than other specialties

• Payers often consider 2 opposing goals when managing oncology1

– Find ways to more aggressively control oncology spending

– Craft management policies that are politically and clinically defensible

• Payers focus their management attention on the most prevalent and high-cost cancer types to generate the largest return for their efforts in developing and implementing management programs– These cancer types are:

1. McConnell K, Wu J, Dautel N. Payers Must Create Defensible Oncology Management Strategies. Oncology Business Review. 2010

Breast Lung Colon


Payers prioritize costs before other relevant oncology issues, like site of care

• Although the provider landscape in oncology is rapidly changing, payers prioritize other aspects of oncology care before the movement of community-based care to hospital-affiliated practices

• Priorities remain cost drivers such as the cost of hospitalizations or the cost of high-priced products

1. Xcenda. Managed Care Network. PayerPulse June 2012.

1 - Not at all a priority 4 - Neutral 7 - Extremely high priority0%

10%

20%

30%

40%

50%

60%

70% Payer Priorities in Oncology1

Movement of community-based care to hospital-af-filiated practices

Cost of Hospital-izations

High-priced new products

Payer Priorities in Oncology1

1. High-priced new products2. Cost of hospitalizations3. Ability to compare and analyze

pharmacy and medical benefit4. Need to increase use of generics5. Appropriate use of biomarkers6. Pathway implementation7. Appropriate use of hospice8. Compliance and persistency with

oncology drugs9. Cost of emergency room visits10.Movement of community-based

care to hospital-affiliated practices

11. Role of 340B


There also appears to be a disconnect between payer and provider preferences for acquiring infused therapies; payers prefer SPP, while providers demonstrate a preference for buy-and-bill

1. Snyder M, Goldberg L, Ryan T. Payer Management of Oncology Gets Serious. Pharmacy Times. http://www.pharmacytimes.com/publications/specialty-pt/2011/May2011/Payer-Management-of-Oncology-Gets-Serious. Accessed August 17, 2012.

42%

53%

2% 3%

Payers’ Preferred Infused Therapy Distribution Channel1

Buy-and-bill Specialty vendorPatient acquisition Other

Providers’ Primary Infused Therapy Acquisition Channel1

• >70% of infused therapies for oncology are distributed via buy-and-bill1

• Average sales price (ASP) used as the primary method of reimbursement by payers

http://www.pharmacytimes.com/publications/specialty-pt/2011/May2011/Payer-Management-of-Oncology-Gets-Serious


The Challenge of Establishing the Site of Oncology Care Payer Value Proposition

• There is somewhat of a disconnect between payers and oncology providers

– Payers have other priorities in oncology that supersede site of care, despite the recent market

changes

• Payers lack awareness of the value that community oncology practices bring to the market

– Preferences for product acquisition vary and create an additional point of discussion and

negotiation between the 2 groups

• Payers are seeking additional payment models that make oncology practices’ income independent of drug

selection and reward physicians for improving outcomes and reducing costs

• As heard in a recent payer focus group, smaller regional payers may have different views,

needs, and opinions than larger national payers1

– National payers may have more lucrative contracts with hospitals, particularly larger hospital

systems, than with smaller community practices, and therefore, may see comparable costs in

patients treated in the hospital outpatient department (HOPD) setting

• The opposite being true for smaller payers

• Mid-size plans are more undecided and potentially able to be persuaded either way

• Payers are also looking for a demonstration of quality as part of the value equation1

– ie: Value = Quality / Cost1. Xcenda, data on file. Oncology Site of Care Virtual Payer Council. September 2012.

Community vs Hospital-based Oncology Care


While HOPDs often profess to care for sicker patients to justify their higher costs, recent claims analyses show similarities in the demographics of office-managed vs HOPD-managed breast, lung, and colorectal cancer patients1

1. Xcenda, data on file. Site of Care Claims Analysis Report. September 2012.

Male Female0

20

40

60

80

100

Patients by Gender in Select Tumor Types1

Office HOPD

Gender

% o

f p

ati

en

ts

• Patient illness severity is roughly the same in the community practice setting as the HOPD setting across these 3 tumor types

Charls

on c

omor

bidity

inde

x

# of

uniq

ue d

iagno

ses

# of

uniq

ue p

resc

riptio

ns0

5

10

Patient Severity in Select Tumor Types1

Office HOPD

Sc

ore

/Nu

mb

er

• Slightly more females than males are treated in the HOPD compared to community practices

• The mean age of patients in the community practice setting is slightly higher than in the HOPD setting (58.7 years vs 56.9 years, respectively)



• Three separate analyses of managed care claims in commercial and Medicare populations demonstrate that patients managed in a community office setting cost less than patients managed in a hospital-based outpatient setting1-3

– The difference in cost varies for individual tumor types; however, the data suggest that this applies to breast, lung, and colorectal cancer3

• Evidence suggests that patients managed in a community office setting have lower hospitalization rates than patients managed in a hospital-based outpatient setting

• The majority of common breast, colorectal, and lung cancer chemotherapy-specific costs are lower for patients managed in a community setting

Patients managed in an office-based

setting are less costly than those

managed in hospital outpatient

settings

1. Avalere Health Analysis Report of National Association of Managed Care Physicians member data. Total cost of cancer care by site of service: physician office vs outpatient hospital. March 2012.

2. Fitch K, Pyenson B. Site of service cost differences for Medicare patients receiving chemotherapy. Milliman Client Report. 2011.

3. Xcenda, data on file. Site of Care Claims Analysis. September 2012.


Analysis of 4 large commercial health plans reveals that patients who are managed in an office setting are 24% less costly than hospital-managed patients for common cancer types1


Types of cancer

Office-managed episodes

HOPD-managed episodes %

difference in average

episode cost

# of episodes

Average episode

cost

# of episodes

Average episode

cost

Prostate 3,503 $21,299 394 $25,504 19.7%

Genitourinary system

3,152 $8,960 655 $19,592 118.7%

Breast 2,252 $30,072 860 $33,391 11.0%

Lung 3,036 $32,913 1,239 $32,382 -1.6%

Colon 973 $45,997 233 $46,220 0.5%

Digestive system

688 $30,018 266 $30,044 0.1%

Leukemia 581 $39,008 350 $43,508 11.5%

Hodgkin’s/ lymphoma

2,131 $39,080 902 $42,537 8.8%

Office-managed chemotherapy

HOPD-managed chemotherapy

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$28,200

$35,000

Average Cost of Chemo-therapy for Most Common

Cancer Types

24% Differ-ence


There was a 114% difference in the average cost of episodes for office-managed patients ($26,800) vs HOPD-managed patients ($57,400) over 9 months1


Length of episode in

months

Office-managed episodes HOPD-managed episodes% difference in average

episode costs# of episodesAverage

episode cost# of episodes

Average episode cost

1 4,601 $7,350 1,784 $9,903 34.7%

3 2,502 $19,238 1,091 $24,592 27.8%

5 1,601 $26,979 481 $40,677 50.8%

7 1,091 $26,395 268 $40,879 54.9%

9 734 $26,794 127 $57,384 114.2%

11 302 $47,468 69 $63,366 33.5%


In a Medicare population, office-managed patients cost $6,500 less per year than hospital-managed patients


Office-managed chemotherapy HOPD-managed chemotherapy$44,000

$46,000

$48,000

$50,000

$52,000

$54,000

$56,000

$47,500

$54,000

Annual cost per patient

$6,500 Difference


Hospital-managed patients with breast, colorectal, and lung cancer were more costly than community-managed patients1


Breast Colorectal Lung$0

$5,000

$10,000

$15,000

$20,000

$25,000

$8,344

$11,599$10,272

$12,318

$19,136

$13,577

Mean Chemotherapy Costs – All RegimensCommunityHospital


Breast cancer patients managed in a hospital-based setting are more costly in all treatment categories1


$0

$5,000

$10,000

$15,000

$20,000

$25,000

$9,403

$2,504

$15,545

$2,348

$7,668

$4,831

$10,593

$13,149

$3,052

$20,236

$3,899

$18,493

$12,860

$14,474

Breast Cancer Treatment Costs Community

Hospital


Colorectal cancer patients managed in a hospital-based setting are more costly in all treatment categories except bone metastasis agents1


$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$10,345

$1,870

$16,214

$11,644

$5,471

$14,517$15,902

$330

$32,010

$15,033

$5,552

$73,920

Colorectal Cancer Treatment Costs Community

Hospital


Lung cancer patients managed in a hospital-based setting are more costly in most treatment categories1


$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$9,580

$4,131

$14,891

$9,565

$13,391 $13,505$13,632

$6,051

$15,050$14,693

$30,665

$12,644

Lung Cancer Treatment Costs Community

Hospital


In the same analysis, office-managed patients also had fewer hospitalizations during chemotherapy

• An analysis of 3 years of commercial health plan data reveals that oncology patients treated in an HOPD have higher hospitalization rates


Office-managed

11 out of every 100 patients had at least 1 hospitalization during the chemotherapy

episode

HOPD-managed

14 out of every 100 patients had at least 1 hospitalization during the chemotherapy

episode


The majority of common breast, colorectal, and lung cancer chemotherapy-specific costs are lower for patients managed in a community setting1


CTX + DOXO CTX + DTX ZA CTX + DOXO + DTX CPL + DTX + trastuzumab

$0

$5,000

$10,000

$15,000

$2,267 $4,460$909

$5,482$10,518

$1,291

$6,615

$1,033

$7,828

$13,754Breast Cancer Mean Chemotherapy-specific Costs

5-FU + LV + OX 5-FU BEV + 5-FU+ LV + OX 5-FU + LV OX$0

$20,000

$40,000

$60,000

$6,922$824

$13,204 $792 $5,474$5,544 $4,169

$41,482

$534 $5,133

Colorectal Cancer Mean Chemotherapy-specific Costs

PL + PTX/ETO PL + DTX BEV+ PL + PTX/ETO PL + GC PL + VNR/TPT$0

$5,000

$10,000

$15,000

$1,618$4,165

$8,725

$3,111 $1,637$2,901

$8,781

$14,002

$8,869

$1,377

Lung Cancer Mean Chemotherapy-specific Costs

Key: CPL – carboplatin, CTX – cyclophosphamide, DOXO – doxorubicin, DTX – docetaxel, ZA – zoledronic acid

Key: CPL – 5-FU – fluorouracil, BEV- bevacizumab, LV – leucovorin, OX - oxaliplatin

Key: BEV- bevacizumab, DTX – docetaxel, ETO – etoposide, GC – gemcitabine, PL – platinum, PTX – paclitaxel, TPT – topotecan, VNR - vinorelbine


HOPD costs are 40% to 54% higher than community practices for patients receiving non-targeted chemotherapy in breast, lung and colorectal cancers. This is primarily driven by physician costs being 89% to 1242% higher in HOPD vs community1


Community Hospital$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

$16,000

$18,000

Breast Cancer Non-targeted Chemother-

apy Combinations


$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

$16,000

$18,000

Lung Cancer Non-targeted Chemother-

apy Combinations


$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

$16,000

$18,000

Colorectal Cancer Non-targeted Chemotherapy

Combinations

$9,403

$13,149

$10,345

$15,902

$9,580

$13,632


HOPD costs are 30% to 97% higher than community practices for patients receiving targeted chemotherapy in breast and colorectal cancers; however, lung cancer costs are comparable1



$5,000

$10,000

$15,000

$20,000

$25,000

Breast Cancer Targeted Chemotherapy


$5,000

$10,000

$15,000

$20,000

Lung Cancer Targeted Chemotherapy


$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

Colorectal Cancer Targeted Chemother-

apy

$15,545

$20,236

$16,214

$32,010

$14,891 $15,050



Care provided in community office-based settings is more accessible

and less costly for patients

• Patient out-of-pocket amounts are higher for patients managed in an HOPD setting

• Most common chemotherapy regimens for breast, colorectal, and lung cancers are associated with lower patient out-of-pocket payments in a community office setting

• When patients receive care in an HOPD setting, they are more likely to wait longer for their first chemotherapy treatment

• Patients in rural areas are more likely to visit community office practices, indicating that community care is more accessible to these populations


In a Medicare population, patient out-of-pocket amounts are 10% higher for patients receiving chemotherapy in hospital outpatient settings1


2. Neumann P, Palmer J, Nadler E, et al. Cancer therapy costs influence treatment: a national survey of oncologists. Health Affairs. 2010;29(1):196-202.

84% of oncologists say that patients’

out-of-pocket spending influences

treatment recommendations2

Cancer Type Office-managed Chemotherapy

Hospital-managed Chemotherapy

Breast $759 $814

Colon $938 $975

Lung $852 $847

Rectal $690 $800

All cancers $700 $773


With respect to common breast, colorectal, and lung chemotherapy regimens, most patient out-of-pocket costs are higher for hospital outpatient-managed patients1


CTX + DOXO CTX + DTX ZA CTA + DOXO + DTX CPL + DTX + trastuzumab

$0

$10,000

$224 $561 $310 $344 $571$116$2,305

$176 $725

$5,376

Mean Patient Out-of-Pocket Costs for Breast Cancer Chemotherapy Regimens

5-FU + LV + oxaliplatin 5-FU BEV + 5-FU+ LV + OX 5-FU + LV OX$0

$10,000

$829 $159 $1,051 $120 $1,087$958 $0 $95 $6$1,642

Mean Patient Out-of-Pocket Costs for Colorectal Cancer Chemotherapy Regimens

PL + PTX/ETO PL + DTX BEV + PL + PTX/ETO PL + GC PL + VNR/TPT$0

$10,000

$496 $718$2,466

$471 $441$288

$5,347

$8,342

$1,781$3,270

Mean Patient Out-of-Pocket Costs for Lung Cancer Chemotherapy Regimens

Key: CPL – carboplatin, CTX – cyclophosphamide, DOXO – doxorubicin, DTX – docetaxel, ZA – zoledronic acid

Key: CPL – 5-FU – fluorouracil, BEV- bevacizumab, LV – leucovorin, OX - oxaliplatin

Key: BEV- bevacizumab, DTX – docetaxel, ETO – etoposide, GC – gemcitabine, PL – platinum, PTX – paclitaxel, TPT – topotecan, VNR - vinorelbine


Access to community clinics is vital for patients in rural areas and Medicare beneficiaries without supplemental insurance1

1. Shea AM, Curtis LH, Hammill BG, et al. Association between the Medicare Modernization Act of 2003 and patient wait times and travel distance for chemotherapy. JAMA. 2008;300(2):189-196.

Location of first chemotherapy course, n (%)

Patients in rural areasn=188

Medicare beneficiaries without supplemental insurance

n=66

Hospital infusion center/clinic 42 (22.3) 14 (21.2)

Hospital inpatient facility 21 (11.2) 6 (9.1)

Infusion center affiliated with private oncology practice 60 (31.9) 21 (31.8)

Private doctor’s clinic 56 (29.8) 22 (33.3)

Changing Oncology Market Landscape



Patients in community

settings utilize more generics and

less brand therapies, which result in savings

for payers

• Breast, colorectal, and lung patients managed in a community setting are prescribed generic chemotherapy more frequently

• The maturing oncology portfolio will bring savings through competition and higher generic utilization in a community setting

• Breast, colorectal, and lung patients managed in a hospital setting are prescribed brand treatments more frequently

• An active pipeline creates more opportunity for payers to adopt aggressive management policies for hospital-based providers with high brand utilization


Breast, colorectal, and lung patients managed in a community setting are prescribed generic chemotherapy more frequently1


Breast Colorectal Lung0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

67% 68%

77%

57% 58%

72%

Proportion of Patients Prescribed Generic Chemotherapy Only

Community

Hospital


The maturing oncology portfolio will bring savings through competition and higher generic utilization in a community setting

2023Thalomid

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 202340

50

60

70

80

90

100

110

120

Gen

eric

/Pat

ent

Exp

irat

ion

2005Duragesic Transdermal Sandostatin

2006Zofran

2007KytrilGemzar

2008FemaraCamptosarFosamax

2011EtopophosXelodaAromasin FemaraAnzemetIstodaxPlavixAvonexNeumega

2012EloxatinEnbrelVidaza

2013NeupogenZometaXelodaTaxotereTemodarDacogenEpogenProcritRemicade

2014RemicadeLeukineRapamuneEvistaXeloda

2015EpogenAranespRituxanEpogenProcritGleevecAloxiNeulastaPeg-IntronEmend oralAlimta

2017NeulastaSandostatinVelcadeTysabriIressaVelcadeXolair

2018TarcevaAvastinHerceptinClolar

2019RevlimidZytigaExjadeBonivaOrencia

2020NexavarTykerbRevlimidVectibixSprycel

2021SutentSoliris

Generic Introduced Patent Expiration

2016EnbrelErbituxZevalinElitekHumiraPrialt

185% incre

ase in ava

ilable

generics/b

iosimila

rs

By 2020, there will be a robust portfolio of generic and biosimilar treatments


Breast, colorectal, and lung patients managed in a hospital setting are prescribed brand treatments more frequently1


Breast Colorectal Lung0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

32% 32%

23%

43% 42%

28%

Proportion of Patients Prescribed Any Branded Chemotherapy

Community

Hospital


An active pipeline creates more opportunity for payers to adopt aggressive management policies for hospital-based providers with high brand utilization

• The presence of numerous treatment options gives payers the opportunity to adopt more aggressive management policies by leveraging competitive market dynamics

Unspecified cancersOther cancers

Cancer-related conditionsStomach cancer

Solid tumorsSkin cancer

SarcomaProstate cancer

Pancreatic cancerOvarian cancer

Multiple myelomaLymphoma

Lung cancerLiver cancer

LeukemiaKidney cancer

Head/neck cancerColorectal cancer

Cervical cancerBreast cancerBrain cancer

Bladder cancer

0 50 100 150 200 250

78

98

32

24

240

65

21

80

41

49

49

97

98

31

108

31

21

55

9

91

52

14

Nearly 900 drugs in de-velopment for cancer



Community practices are more

willing to participate in pay-for-quality pathway programs, which will translate into

improved outcomes and

savings for payers

• Evidence demonstrates community oncology practices are more likely to participate in pathways or pay-for-quality programs

• Pathway programs result in reduced costs of cancer care by reducing the rate of both drug and nondrug expenses

• High community practice participation rates in pathways programs creates an opportunity for payers to improve care and reduce costs


An opportunity exists for payers to leverage community oncology practices’ willingness to participate in pay-for-quality pathway programs

• Evidence demonstrates community oncology practices are more likely to participate in pathways or pay-for-quality programs1

– In a study where 362 oncology practices were eligible for participation, the highest participation rate was observed in community oncology practices1

– In a related study, the pathway program resulted in reduced costs of cancer care by reducing the rate of both drug and nondrug expenses2

– Total savings, factoring out the increased fee schedule for participating practices, was estimated at $8,585,1482

• Furthermore, pilot pathways programs suggest that the saliency of pay-for-quality incentives in academic and hospital settings should be further studied1

1. Fortner BV, Wong W, Olson T, et al. Year one evaluation of participation and compliance in regional pay for quality (P4Q) oncology program. Poster presented at: International Society for Pharmacoeconomics and Outcomes Research; Atlanta, GA: May 15–19, 2010.

2. Scott JA, Wong W, Olson T, et al. Year one evaluation of regional pay for quality (P4Q) oncology program. J Clin Oncology. 2010;28(Supl 15):6013.

Overall Community participants

Hospital-based

participants

Academic participants

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

49%

88%

44%

6%

Participation in Pay-for-Quality Pathways by Practice Type (n=362

practices)

Summary



• Three separate analyses of managed care claims in commercial and Medicare populations demonstrate that patients managed in a community office setting cost less than patients managed in a hospital-based outpatient setting

• Patients managed in a community office setting have lower hospitalization rates than patients managed in a hospital-based outpatient setting

• The majority of common breast, colorectal, and lung cancer chemotherapy-specific costs are lower for patients managed in a community setting

Patients managed in an office-based setting are less costly than those managed

in hospital outpatient settings

• Patient out-of-pocket amounts are higher for patients managed in an HOPD setting

• Most common chemotherapy regimens for breast, colorectal, and lung cancer are associated with lower patient out-of-pocket payments in a community office setting

• When patients receive care in an HOPD setting, they are more likely to wait longer for their first chemotherapy treatment

• Patients in rural areas and Medicare patients without supplemental insurance are more likely to visit community office practices, indicating that community care is more accessible to these populations

Care provided in a community office-based

setting is more accessible and less costly for patients

• Breast, colorectal, and lung patients managed in a community setting are prescribed generic chemotherapy more frequently

• The maturing oncology portfolio will bring savings through competition and higher generic utilization in a community setting

• Breast, colorectal, and lung patients managed in a hospital setting are prescribed brand treatments more frequently

• An active pipeline creates more opportunity for payers to adopt aggressive management policies for hospital-based providers with high brand utilization

Patients in community settings utilize more

generics and less brand therapies, which results in

savings for payers

• Evidence demonstrates community oncology practices are more likely to participate in pathways or pay-for-quality programs

• Pathway programs result in reduced costs of cancer care by reducing the rate of both drug and nondrug expenses

• High community practice participation rates in pathways programs creates an opportunity for payers to improve care and reduce costs

Community practices are more willing to participate in

pay-for-quality pathway programs, which will translate into improve outcomes and

savings for payers


Recommendations

• Know your audience: – The value messages (as described on the previous slide) are likely to resonate best

with small to mid-size payers

• Educate on cost and quality outcomes in the community setting compared to the HOPD setting

• Smaller payers are likely more in touch with the local providers already, and therefore likely need less convincing; mid-size payers are likely to need the most education and persuading

• Understand the hospital contracts and other drivers for large plans before approaching with these messages and tailor them accordingly

• Generate and publish outcomes data to complete the value equation:– While it has been demonstrated that community practices are more likely to follow and

participate in pay-for-quality programs, the outcomes of those initiatives have not been widely analyzed and published – more data generation and publication on outcomes are needed

Thank you!

Site of Care Matters: The Value of Community Oncology The Payer Value Proposition September 2012...

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