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
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 Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
1) There is now bipartisan, bicameral legislation to reform the sustainable growth rate (SGR) that does not give Congress sticker shock; and
2) The U.S. Department of Health and Human Services (HHS) has declared that that it does not consider health insurance plans and other related federal subsidies that are offered through the new insurance exchanges, to be federal healthcare programs.
The House Energy & Commerce, Ways & Means, and Senate Finance Committees have worked together to introduce policy to repeal the flawed SGR formula with stable payments and quality-based incentive payments moving forward. Energy & Commerce was the first to introduce legislation in September, but the Congressional Budget Office (CBO) estimated the bill would cost $35 billion more over 10 years than the CBO’s most recent scoring for an SGR fix. Now, the Ways & Means and Senate Finance Committees have introduced new legislation more in line with the CBO’s anticipated costs.
This proposed legislation would prevent the 24.4% cut to reimbursement – which is currently set to go into effect on Jan. 1, 2014, unless Congress steps in. Under the new legislation, the SGR formula would be replaced with a pay freeze for the next 10 years. The proposal, which is still in discussion draft form, calls for gradually replacing Medicare’s existing fee-for-service payment system with a “value-based performance system” focused on medical outcomes rather than procedures. This means there will be financial incentives to participate in alternative payment models. Under the draft legislation, it’s possible that reimbursement could be adjusted based on performance as soon as 2017. The bill relies on the Physician Quality Reporting System (PQRS), the value-based modifier, and the EHR Meaningful Use Program – currently penalty-only systems – to create incentive payments for high-quality care. In addition, the proposed legislation would keep the penalty portion of these programs to help fund the incentive payments.
We can all agree that the current SGR formula is fundamentally flawed and that a new reimbursement system is necessary. The CBO has estimated the cost of “freezing” physician Medicare payments for 10 years at $138 billion. While this is a relative bargain in congressional terms, Congress still faces an uphill battle to find the funds to replace the SGR. To date, the draft legislation addresses the policy behind SGR reform only; the battle to identify a ‘pay-for’ has not yet begun.
Exchange Plans Not Federal Programs
With the new insurance exchanges, there has been much confusion concerning whether drug manufacturers would be able to continue certain patient assistance programs because it was unclear whether the new insurance exchanges and their related subsidies were considered federal programs. Generally, drug manufacturers can provide copay assistance to patients who are unable to afford their medication so long as they are not in receipt of assistance through a federal program. Although the insurance plans purchased through the exchanges are private, the fact that they are being offered through a federal marketplace and federal funds are available to offset the cost of premiums led to many unanswered questions. Many drug manufacturers wondered if they would be able to continue to offer patient assistance programs to these needy patients.
Thankfully, in a letter to Congressman Jim McDermott, HHS clarified that qualified health plans and related federal subsidies are not considered federal programs for the sake of manufacturer copay assistance programs. This is great news. The clarification means that drug companies may continue to offer the much needed assistance that many low-income patients have come to rely on.
So forget about the federal government shut down, looming debt ceiling, and other congressional woes for a few minutes. With Thanksgiving approaching, let’s be thankful for a few of the bright spots coming from Washington and, for the moment at least, view the glass as half full.
by Matt Farber, Director, Provider Economics and Public Policy, ACCC
The role of technology in healthcare—and the many headaches that can accompany the adoption of new technology—has been put under the microscope in recent weeks. Missteps and glitches during the roll-out of the new health insurance marketplaces’ online enrollment have some questioning broadly whether technologies designed to improve the healthcare system can actually achieve their goal.
The process may not be easy, but evidence shows that appropriate technology can improve efficiency and coordination in healthcare, whether it’s online insurance enrollment, electronic health records, or—as explored in a new white paper from ACCC—health information exchanges.
ACCC’s new white paper, “Cancer Care in the Age of Electronic Health Information Exchange,” discusses the potential impact of health information exchange on cancer care and the hurdles to adoption. It is the second white paper to come out of ACCC’s Institute for the Future of Oncology, with the first released in October.
Health information exchange describes two related concepts: the electronic sharing of health-related information among organizations, and the entities that provide services to facilitate this electronic information sharing.
“Cancer Care in the Age of Electronic Health Information Exchange” explores the current state of health information exchange adoption, the importance of HIE, and also the potential for improved quality of care and reduced costs that an HIE can provide.
The push for adoption and integration of electronic health records (EHRs) has been a first step toward realizing the capabilities and benefits of electronic health information exchange. Adoption of and engagement in HIEs, the organizations that enable electronic sharing of patient data across providers and healthcare organizations, is the next step—and in many areas of the country, this step is still out of reach.
The white paper reflects discussion and perspectives from participants in the Institute’s inaugural forum, which was held in late June 2013. Here is a snapshot of the white paper’s findings:
- HIE adoption is uneven.
- There is a lack of awareness around HIEs.
- HIE initiatives must focus on information standardization.
- HIEs can help benchmark interventions within patient populations.
- Providers must have input on the information released via patient portals.
The potential of HIEs to improve benchmarking, efficiency, and ultimately quality of care in oncology was universally agreed by participants at the Institute. However, the consensus was that many hurdles remain before the potential becomes reality.
ACCC’s Institute for the Future of Oncology addresses key topics impacting oncology now and in the future. If you would like to get involved in upcoming forums of the Institute for the Future of Oncology, please contact Matt Farber at firstname.lastname@example.org.
By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
The federal government is back in business. On Wednesday evening of this week, the House and Senate passed a continuing resolution to fund the government through January 15, 2014, and raise the debt ceiling until February 7, 2014. So, the shutdown is over, but Congress essentially just kicked the can down the road—and not very far.
The good news? Funding for new clinical trials will be restored and the Centers for Medicare & Medicaid Services (CMS) will get back to writing the final rules for the 2014 Physician Fee Schedule (PFS) and Hospital Outpatient Prospective Payment System (OPPS). However, funding has been restored at post-sequestration levels, and the conversation continues about how this is impacting community cancer care. It’s also possible that the three-week government shutdown may cause a delay in CMS’s release of the final rules, which would mean less time for implementation of the new policies that go into effect on January 1, 2014.
What about hopes for SGR reform? With less than two months remaining in 2013 and Congress focused on little besides the budget and debt ceiling, hopes of passing reform this year are slipping away. This means we are looking at the probability of yet another last-minute “Doc Fix” to stave off the anticipated 25% cut to Medicare reimbursement created by the flawed SGR formula. This year, many in the advocacy community believed that the timing was ripe to finally do away with the SGR given the CBO’s low budget score and the fact that the House Energy & Commerce, Ways and Means, and Senate Finance Committees all drafted legislation. While there is an outside chance that SGR repeal could get looped into a larger budget deal, the current SGR repeal legislation is expected to cost $175 billion over 10 years and no offsets have yet been identified, so Congress will likely wait another day to take on that fight.
Déjà vu all over again? Come January we may see ourselves in the same situation from which we just emerged: partisanship and political gridlock threatening another shutdown. While the conversation on the Hill continues to be budget-driven, ACCC will continue to work with members of Congress to preserve provider reimbursement and access to care for patients. We will be participating in a Hill day next week with other members of the cancer advocacy community to request adequate funding for cancer research and other programs. Please stay tuned for updates.
By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
As you undoubtedly already know, we are in the third week of the government shutdown due to Congress’s inability to agree on a continuing resolution (CR) to fund discretionary spending. This means that discretionary spending has stopped, but mandatory spending for things that protect life, property, and entitlements continues on an automatic basis. What does this mean for cancer care providers?
1) At least in the short term, Medicare reimbursement will continue as usual (at post-sequestration levels).
2) The National Institutes of Health (NIH) will continue with clinical trials currently in progress, but will not begin any new trials until funding is restored.
3) The U.S. Food and Drug Administration (FDA) has furloughed a number of workers, which could slow the approval of new drugs if there is a prolonged shutdown.
The federal government is expected to hit the debt ceiling—the point at which the country cannot borrow new money—on October 17. Speaker Boehner has committed to not reaching the debt limit, even though the House and Senate are still unable to reach a deal that pleases everyone. Some members of the House Tea Party remain committed to only voting in favor of funding if implementation of the Affordable Care Act (ACA) is delayed. Current negotiations would fund the government through the middle of January, and raise the debt ceiling through the middle of February; barely enough time to catch a breath before the threat of shutdown is upon us again.
While Congress continues to negotiate the government’s budget and borrowing limit, other important legislation waits on the sidelines. The status of the sequester remains of specific interest to the oncology community. ACCC continues to support HR 1416, legislation that would exempt cancer drugs from the Medicare sequester. This legislation is becoming increasingly important not only because of its 108 bipartisan cosponsors, but because of the current political climate. Congress is in a deficit-reduction mindset. While they understand that the sequester is a blunt budgetary tool which impacts oncology providers in a particularly unfair manner, they are reluctant to eliminate the sequester because it is saving the government money. In other words, Congress views the sequester as the new normal and proved this by only introducing budget bills with post-sequestration spending levels.
Cancer care providers, please complete ACCC’s follow-up sequester impact survey so we can show how the two percent Medicare sequester is impacting you and your ability to care for patients. As always, ACCC will keep members up to date on this important matter.