By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
In a recent blog, we raised concerns about the slippery slope of CMS’s proposed sweeping changes to the Medicare Part D Program, including a proposal to eliminate at least two of the six protected classes of drugs. ACCC submitted comments, coalesced with 371 organizations to send a letter urging withdrawal of the proposal, and supported the Senate Finance Committee’s request to avoid changes to this already successful program.
ACCC is proud to announce that, thanks to the voices of our members and the work of related organizations, CMS Administrator Marilyn Tavenner has announced that the agency will not be moving forward with four of the proposed changes to the Part D Program, including the proposal related to the “protected classes” definition of three drug classes.
On behalf of Medicare beneficiaries, we thank Administrator Tavenner for this sound decision.
Pay for performance. Bundling. Episodic payments. ACOs. PCMHs. Payment reform buzzwords are now part of the oncology landscape as providers try to envision what the future will look like.
As healthcare reforms move us away from a volume-based payment model toward new value-based models—it’s hard for those on the front lines of cancer care to gauge exactly where oncology is in the transition process.
On April 1, ACCC Annual National Meeting keynote speaker Kavita Patel, MD, MS, will present an insider’s view of the progress to date in the shift from fee for service payment in oncology to quality and value-based models. Dr. Patel is a Fellow and Managing Director in the Engelberg Center for Healthcare Reform at the Brookings Institution. She has been leading efforts around payment reform in oncology in the private and public sector, including advising the recent Specialty Physician Payment Model Opportunities Assessment and Design (SPPMOAD) project of the Center for Medicare & Medicaid Innovation (CMMI). Additionally, her current research focuses on payment models in cardiology, gastroenterology, and primary care. Her knowledge is built on practical clinical experience as a primary care physician as well as her experience serving as a senior advisor to President Barack Obama and the late Senator Ted Kennedy.
In a recent conversation, Dr. Patel gave us a preview of the issues she’ll discuss at the ACCC’s upcoming Annual National Meeting. Read on for a glimpse into how she thinks oncology care delivery may look in the future.
In the near term, Patel believes oncology is likely to experience more pressure to drive down the cost of drugs by forcing doctors not to use high-cost drugs; more pressure for demonstration of adherence to guidelines and pathways; and increasing documentation requirements about patient-reported measures such as pain and symptom management.
Looking further down the road, the many new payment models under consideration make the future a little fuzzier. “Right now in cancer it’s really just fee for service; anything that’s not fee for service would be interesting—ACOs, medical homes, pay for performance, bundled payments, capitation, global budgets,” Patel said. But the move away from fee-for-service is a certainty.
Whatever shape new payment systems take, Dr. Patel thinks it could affect the composition of the oncology workforce. “Our traditional roles might have to be adapted,” she said. “Right now doctors are getting paid to see a lot of patients.” If oncology shifts to value-based payment models, there may be a change in who delivers some patient care. “It might not be doctors and it might not even be nurse practitioners; it may be oncology community health workers.” Who might fill the role of oncology community health worker? Often these staff are lay persons who can help patients navigate the delivery system and serve as a point of coordination and outreach on the many issues which impact health beyond the four walls of a doctor’s office, such as transportation, housing and nutrition, she said.
Dr. Patel will share more insights and help set the stage for meeting sessions that will provide a deeper dive on topics such as strategies for growth in cancer care delivery, alternate payment models in oncology, the role of physician extenders on the cancer care team, and more at the ACCC Annual National Meeting, March 31-April 2, in Arlington, Virginia.
By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
The Centers for Medicare & Medicaid Services (CMS) recently proposed a rule that would bring significant changes to the Medicare Advantage and Part D prescription drug benefit programs. Of the sweeping changes proposed, ACCC is particularly concerned about the agency’s proposal to eliminate at least two of the six protected classes of drugs in 2015, with the possibility of eliminating a third in 2016. And we are not alone. On Feb. 5, the bipartisan membership of the Senate Finance Committee sent a letter to CMS Administrator Marilyn Tavenner asking the agency to drop its proposed limitations on the Part D program; on Feb. 18, more than 200 groups joined in a letter urging CMS to eliminate the proposed change in protected classes; and on Feb. 19, three congressional Republican committee leaders with jurisdiction over Medicare sent a letter to Tavenner asking that CMS withdraw the proposed rule.
Protection for Vulnerable Populations
At the start of the Part D program, CMS recognized the importance of protecting vulnerable patients who might have lost access to their drugs when transitioning into the Part D program and, in response, created the protected classes policy. The regulations require insurance companies to cover all, or substantially all, of the drugs in the six classes of clinical concern (“protected classes”):
Now, in an about-face, CMS is proposing to remove two classes—antidepressants and immunosuppressants—from the protected class status in 2015, with discussion of eliminating the antipsychotic class in 2016.
In its proposal CMS says that the policy has driven up the cost of Medicare Part D, and cites patient protection concerns due to the potential for overutilization. The agency estimates that this proposal, if finalized, will save $1.3 billion between 2015 and 2019.
On the one hand, it’s true that if plans are no longer required to cover all or substantially all of the drugs in a protected class, savings will be realized through Part D. On the other hand, a potential consequence of this change is that costs will rise across the healthcare system as decreased access to drugs will most likely result in increased hospitalizations and emergency room visits—and, ultimately, lead to poorer health outcomes. Certainly this is counter to the aim of providing more patient-centered care.
For the cancer community, CMS’s proposed change represents a dangerous slippery slope. While Part D plans must still cover all or substantially all antineoplastic drugs and oncology providers and their patients are not facing an immediate threat, CMS’s proposal is creating apprehension about the future of the protected classes policy. For those battling cancer, it is imperative that all drugs be available, since each patient reacts differently to each of the medications, and changes in treatment regimens may be required as patients experience side effects or as their condition advances.
CMS should to listen to the outcry of the public and Congress and not erode the protected classes coverage requirements. At the start of the Part D program, CMS created the protected classes requirement in an effort to protect access to needed medications for certain vulnerable populations. Erosion of this policy now will likely have a chilling effect on Medicare Part D enrollment and CMS should not implement this policy.
ACCC will be submitting comments on the proposed rule and will make them available to members on its website. We will keep members updated on this issue.
By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
We’re on the countdown to ACCC’s Capitol Hill Day on March 31. ACCC members who join us will be visiting with congressional staff to speak out on major concerns affecting oncology care. Those on the front lines of cancer care can deliver a powerful, clear message on issues affecting cancer patients and providers. Patient access to care—in particular to anti-cancer medications—is a cross-cutting concern.
Where Things Stand in Congress—Two Bills
Many health insurance plans cover IV chemotherapy, injected anti-cancer medications, and oral anti-cancer drugs differently, causing patients to pay far more out-of-pocket for oral drugs than for IV chemotherapy or injected medications. With the ever rising cost of healthcare, insurers employ various methods to keep costs down, including increasingly shifting the cost of prescription drugs to patients. To help patients afford the life-saving medications they need, Congress has introduced two complementary—if not somewhat confusing—pieces of legislation: HR 1801 and companion bill S 1879 to lower the cost of prescription oral chemotherapy drugs, and HR 460, to limit cost-sharing requirements for prescription drugs on specialty tiers. Both bills aim to protect cancer patients in different ways.
Here’s a quick side-by-side comparison of the legislation. For ACCC members joining us for Capitol Hill Day, this snapshot can help you prepare for conversations with congressional staff.
Oral Parity (HR 1801/S 1879)
- Legislation would require insurers to provide coverage for orally administered anti-cancer medication under terms no less favorable than for medication administered intravenously. Insurers may not create parity by raising rates for IV infusions.
- Focus is on cost-sharing across prescription drug coverage and office visit coverage for anti-cancer medications only.
- Requirements: A physician must deem the treatment to be medically necessary for treating cancer, and the treatment must be clinically appropriate in terms of type, frequency, and duration.
- Types of insurance affected: Group and individual private plans and self-insured group plans regulated by ERISA that cover oral and IV-infused anti-cancer medications.
Specialty Tier (HR 460)
- Legislation would limit cost-sharing requirements applicable to prescription drugs in a specialty tier to the dollar amount of such requirements applicable to prescription drugs in a non-preferred tier.
- Focus is on cost-sharing in prescription drug coverage plans and formularies for any specialty-tier drug covered by the plan.
- Requirements: A health plan that provides coverage for prescription drugs using a cost-sharing structure shall not impose cost-sharing requirements applicable to prescription drugs in a specialty drug tier that exceed the dollar amount of cost sharing for drugs in a non-preferred brand tier.
- Types of insurance affected: Group and individual private plans that cover prescription drugs and use a formulary or other tiered cost-sharing structure. Bill language is unclear as to whether ERISA plans are affected.
Both bills help protect patient access to affordable prescription drugs. However, because oral parity legislation already has 67 co-sponsors in the House and a companion bill in the Senate, this will most likely move through Congress first. Therefore, ACCC will be advocating for oral parity (HR 1801/S 1879) in both chambers on Hill Day. In addition, we will be talking to our representatives about SGR reform, elimination of cancer drugs from the 2% Medicare sequester, and elimination of the prompt pay discount. Learn more about Hill Day 2014 and register today.
As most of you know, we are currently in the midst of a short-term, three-month Sustainable Growth Rate (SGR) patch that was passed by Congress to avert a roughly 24% physician pay cut, which would have gone into effect on Jan. 1, 2014. This short-term fix was passed in order to give Congress more time to work out the differences between three proposed plans to permanently fix the SGR formula. On Thursday, February 6, Congress unveiled a bipartisan, bicameral bill in the hopes of achieving passage before the current “patch” expires. Here are some of the pertinent details:
- 0.5% increase in payments each year for a 5-year span
- Consolidation of current quality reporting mechanisms (PQRS, VBM, Meaningful Use) into one program that will reward physicians who meet certain performance standards
- Rewards of up to a 5% bonus payment to physicians who receive a certain portion of revenue from alternative payment models (such as medical homes, ACOs, etc.)
- Quality and utilization data to be posted to the Physician Compare website.
This newest effort is certainly a step in the right direction. While ACCC would like to see larger annual increases, we are pleased that positive updates were included in the final bill. The biggest hurdle to passage remains the price tag—which is now estimated to be roughly $120 to $140 billion over 10 years. And, legislators have yet to spell out how Congress will pay for this fix.
ACCC will closely monitor this effort, and also work with elected officials as offsets begin to be discussed. If you have any questions, please contact firstname.lastname@example.org or email@example.com.
by Amanda Patton, Manager, Communications, ACCC
No one would argue with the fact that stresses related to the financial burden of the cost of cancer treatment are the last thing cancer patients and their families need. And yet, according to the most recent ACCC Trends in Community Cancer Centers survey, 88 percent of respondent cancer programs reported seeing more patients needing help with prescription drug expenses, co-pays, and co-insurance.
According to a study from Duke University, many cancer patients would like to talk about the cost of treatment with their healthcare providers, but for a variety of reasons, these conversations often do not happen.
However, this may be changing. Along with renewed emphasis on the importance of distress screening and meeting the psychosocial needs of patients comes an increased awareness of the importance of enabling patients to focus on healing rather than on struggling with the financial side effects of care. Many cancer programs are adding staff to serve as financial advocates to help patients and their families; others are working to provide these services with existing staff.
ACCC’s newly released 2014 Patient Assistance and Reimbursement Guide is a user-friendly resource designed to help cancer programs in this effort. This is the fourth year ACCC has published the guide, which is available in both a print and digital format and includes links directly to patient assistance programs, the forms patients and providers need, and much more. The guide includes information on pharmaceutical and non-pharmaceutical patient assistance programs and reimbursement resources, as well as:
- Financial counselor and patient advocate position descriptions
- A tool to estimate patient responsibility of treatment costs
- A charge capture flow chart
- A patient assistance checklist for uninsured patients
- A co-pay assistance checklist.
ACCC offers additional resources through its Financial Information and Learning Network, which includes online courses and tools for providers to help in providing patients with financial assistance services. Finally, an upcoming session on “Financial Advocacy: Improving the Patient Experience” at the ACCC 40th Annual National Meeting will discuss strategies to meet patients’ evolving financial advocacy needs.
by Amanda Patton, Manager, Communications, ACCC
This week Health Affairs announced its 15 most-read articles of 2013. Topping the list: “What It Will Take to Achieve the As-Yet-Unfulfilled Promises of Health Information Technology” (January 2013). Authors Arthur Kellermann and Spencer Jones of the RAND Corporation re-visit a 2005 Health Affairs article from a team of RAND researchers that projected savings of more than $81 billion annually from rapid adoption of health information technology.
Seven years down the road—the picture is not so bright. Kellerman and Jones report that data show health IT’s impact on healthcare efficiency and safety is mixed and, meanwhile, annual expenditures on healthcare in the U.S. have grown by $800 billion. The authors cite a number of hurdles impeding progress toward realizing health IT’s full promise. These include selection of systems that lack interoperability and are not easy to use, along with failure on the part of providers and healthcare systems to re-engineer care processes to fully take advantage of the benefits of health IT.
Still, the authors are optimistic that the original promise of health IT can be realized. However, they say for this to happen we need standardized, easy to use systems; more interoperability; increased patient control of their healthcare information; and providers to re-engineer their care processes to fully benefit from the efficiencies offered by health IT.
Health Affairs is offering free access to all of its top 15 articles until January 28.
On the theme of the yet-to-be-realized potential of health IT, ACCC’s white paper Cancer Care in the Age of Electronic Health Information Exchange offers oncology-specific perspective on adoption and integration of health information exchanges (HIEs), a key component of health IT. Developed through ACCC’s Institute for the Future of Oncology, the paper reflects a forum discussion of current barriers and successes in adoption of HIE. Among the key findings:
- HIE adoption is uneven. Despite the potential that HIEs have to improve patient care, reduce redundancies, lower costs, and demonstrate quality—for example, by allowing participating providers to benchmark interventions within their own patient populations—the oncology community is experiencing patchy adoption and implementation, with the potential being realized in some areas but not others.
- There is lack of awareness around HIEs. There are many known benefits to participation in an HIE, but information about these benefits needs to be more widely disseminated.
- HIE initiatives must focus on information standardization, so that data can be easily exchanged by providers and viewed by patients.
- Challenges remain as to how to achieve interoperability so that data can be exchanged seamlessly across large geographic areas while best ensuring privacy and security.
- Providers must have input on the information released via patient portals. Patient portals can contribute to patient empowerment, but protocols must be put in place so that providers have input on the information released and the timing of that release, and have the opportunity to answer patient questions.
It’s no surprise that many of the issues identified in ACCC’s white paper—the need for standardization, interoperability, ease of use, and provider involvement in health IT processes—resonate with the findings of Kellerman and Jones. While remaining optimistic, there is consensus that much work remains to be done.
by Amanda Patton, Manager Communications, ACCC
Saturday January 11 marks the 50th anniversary of the first Surgeon General’s Report on Smoking and Health. This landmark report was an opening salvo in a sustained fight to reduce smoking and curb its devastating effects. While we’ve made remarkable progress—smoking rates among U.S. adults have been cut in half since 1964—tobacco use is still the leading preventable cause of disease, disability, and death in the U.S.
A study in this month’s Journal of the American Medical Association provides perspective on the powerful impact tobacco control efforts have had on public health in this country. In the decades since the Surgeon General’s first report, the study estimates 8 million premature deaths from smoking have been avoided.
And yesterday’s report from the Centers for Disease Control and Prevention (CDC) on the decrease in new lung cancer rates among men and women in the United States from 2005 to 2009 is more good news.
Still, the fight goes on. Here are some sobering facts from the CDC on the economic costs of smoking:
- During 2000–2004, cigarette smoking was estimated to be responsible for $193 billion in annual health-related economic losses in the U.S. (nearly $96 billion in direct medical costs and an additional $97 billion in lost productivity).
- Cigarette smoking results in 5.1 million years of potential life lost in the U.S. annually.
- Each day in the U.S., nearly 4,000 people younger than 18 years of age smoke their first cigarette
- An estimated 1,000 youth in that age group become new daily cigarette smokers.
The 50th anniversary of the first Surgeon General’s Report is a renewed call to action on this public health issue. Community cancer centers are important partners in the fight to end smoking and its negative health effects. Across the country, community cancer programs are participating in outreach education to schools and communities on the hazards of tobacco use, as well as providing lung cancer screening, diagnosis, treatment, and smoking cessation support. The recent U.S. Preventive Services Task Force Recommendation for lung cancer screening for those at high risk will further enable community cancer centers to identify and treat tobacco-related lung cancers.
Next week, a 50th Anniversary Surgeon General’s Report (SGR) on smoking and health is slated for release. This new report will highlight the progress that has been made in tobacco control and prevention, present new data on the health effects of tobacco use, and detail initiatives that can end the tobacco use epidemic in the U.S.
The Association of Community Cancer Centers will continue to support its membership in this fight by providing practical resources and peer-to-peer learning opportunities. Look for an upcoming article in Oncology Issues on implementing the latest lung screening recommendations in the community setting.
We can all hope that this fight will not last another 50 years.
To celebrate the New Year in 2012, I wrote a forward-looking blog with month by month predictions of what would happen in Congress and with Medicare during the coming year, and how those changes would affect community cancer care. For 2013, I decided to put the crystal ball aside (although some of my predictions for 2012 were pretty spot on—click here to see how I did), and shared some New Year’s Resolutions focused on getting involved with grassroots activities to spotlight key issues facing oncology in 2013. This year, I can’t resist gazing into the crystal ball again and coming up with some predictions, although as always, I make no guarantees….
SGR Reform: Throughout 2013 the cost estimates for a permanent SGR fix continued to decrease, with the cost now standing at roughly $120-150 billion. Three congressional committees have introduced SGR-fix legislation, and two committees have passed their proposed legislation with overwhelming support. Still, cost remains the sticking point, and the question of how Congress will pay for a long-term fix remains as yet unanswered. While I do not have any suggestions for that, I do believe Congress will act and pass a long-term SGR fix in 2014. Here’s why:
- Universal support—Everyone in Congress hates the SGR, and would like this flawed formula to go away.
- Similar bills—The House and Senate versions of the SGR-fix legislation are very similar, therefore there is less chance of disagreement between the chambers.
- Low cost—$120 billion is still a lot of money, but given that the previous cost estimates were north of $300 billion, the current price tag of $120-$150 billion is a relative bargain.
- Senator Baucus’s retirement—Senator Baucus (D-MT) will be leaving the Senate in 2014. Fixing the SGR has been a long-time goal for the Senator, so I think we will see a renewed push to get this done.
Sequestration: With the budget deal framework agreed to in December 2013, Congress is rolling back many of the scheduled cuts due to sequestration; however, the Medicare cuts are not included in those rollbacks. Therefore, the 2% reduction to Medicare payments, including drugs, will remain in place. In fact, Congress has even extended the sequester for two more years, so the Medicare cuts are now scheduled to run until 2023. In 2014, ACCC and other organizations will ramp up their efforts to have drugs removed from the sequester cuts by supporting HR 1416 and advocating for this bill to be attached to a larger legislative vehicle, such as the bill to extend the debt ceiling, which is slated for debate in February and March. In order for ACCC to succeed, we need our members to call their elected officials and let them know what the 2% reductions have meant to them and their patients. Congress needs to hear how these cuts are impacting all patients.
Oral Parity: The effort to pass oral parity legislation in every state continues in 2014, with more states taking up the issue. Many states, including Missouri and Michigan, will be carrying over their 2013 debate on this issue, and ACCC and its partners will be advocating for passage of this important legislation. The effort to pass oral parity on the national level took a giant step in the right direction with the introduction of a Senate companion bill (S. 1879) in December 2013. ACCC will work with its partners in the PEAC and SPEAC coalitions to further support these efforts.
Marketplaces: Open enrollment for the insurance marketplaces kicked off in late 2013, and in 2014 coverage under these plans will start. After a very bumpy rollout, patients who signed up for insurance will now have coverage through these plans. The concerns that ACCC has expressed regarding adequate coverage for cancer patients remain in 2014. Many of the plans offered through exchanges may require high out-of-pocket costs, or may leave certain physicians, treatments, or hospitals out of network. ACCC will continue to work with partners on projects such as the Cancer Insurance Checklist to help educate patients and providers on the best plans for cancer patients.
My final prediction is that 2014 will be an exciting year for the oncology community. ACCC will continue to provide resources to its members and to be their voice with lawmakers. This year, as every year, we need your help. Sign up to participate in our Capitol Hill Day on March 31, 2014, being held as part of the ACCC 40th Annual National Meeting. Attend our spring regional meetings in Minneapolis, Salt Lake City, and Columbus to keep up to date on the latest trends in reimbursement and policy. And as always, if you have any questions, please contact me at firstname.lastname@example.org.