On March 26, by a vote of 392-37 the U.S. House of Representatives overwhelmingly passed H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015, legislation to permanently repeal and replace Medicare’s sustainable growth rate (SGR) formula for physician reimbursement. Read a summary of the legislation here.
Rep. Michael C. Burgess, MD, (R-Texas), the bill’s primary sponsor, said in a statement, “This is the work of a collaborative body. . . .It is time to end the SGR. Let us never speak of this issue again.”
On March 25, the White House expressed support for the bill.
The Senate is expected to vote on the bill March 27, before Congress recesses for two weeks.
ACCC urges members to contact your Senators and ask them to support a permanent repeal of the SGR. As an expert in cancer care, they need to hear from you!
by Amanda Patton, ACCC Communications
March 23 marked the five-year anniversary of President Obama’s signing of the Affordable Care Act into law. Over the last five years, nearly 16.4 million Americans have gained health coverage under the ACA.
Last week, at ACCC’s Annual Meeting, CANCERSCAPE, in Arlington, Va., panelists Steven D’Amato, BSPharm, BCOP, executive director, New England Cancer Specialists; Wendy Andrews, BS, practice manager, Hematology/Oncology at the University of Arizona Cancer Center; and George Dahlman, executive vice president, Federal Affairs & Operations, National Patient Advocate Foundation, explored the impact of the ACA from the patient advocate and provider perspective, sharing the view from the frontlines of care delivery and patient advocacy. The discussion was moderated by ACCC Executive Director Christian Downs, JD, MHA.
One challenge panelists identified is meeting the increased demand for services driven by growing numbers of insured patients.
“In Maine we have an exchange, Maine Community Health Options. It’s been so successful that the challenge is having adequate staff to manage the program,” said Steven D’Amato. “The big challenge will be the workforce challenge as we have more insured patients.”
Wendy Andrews, who is a practice manager, noted that Arizona has expanded Medicaid, which has moved many patients from self-pay to Medicaid. While they are seeing more patients with insurance, these patients all tend to be underinsured.
Another challenge expressed by each of the panelists is the pressing need to help patients understand their insurance coverage and, especially, their out-of-pocket costs.
During the first year of the Marketplace in Arizona, those trying to help consumers with plan selection often had a lack of knowledge [about coverage] and patients were “actually given the wrong information,” Ms. Andrews said. Now, in the Marketplace’s second year, this problem continues.
From the patient advocate’s perspective, George Dahlman finds that the Marketplace experience is exposing consumers’ education gaps. “We have 200 case workers that help patients with insurance problems and copay programs. [This is exposing] the biggest education gaps for consumers. Most people look at the insurance premiums—not what’s included in the benefits program” when purchasing coverage.
Andrews agreed, finding that “ninety percent of all patients really, truly do not understand their insurance benefits.”
Providers and patient advocate organizations alike are challenged to help educate consumers about their coverage. “These are complicated insurance products, and you’re educating two patient populations: previously insured and those who’ve never had insurance before. It’s a brave new world for consumers,” said Dahlman. Patients need information about whether they can keep their current providers when considering insurance options, and what their out-of-pocket costs will be.
“In our practice, it’s essential that patients meet with a financial advocate first,” said D’Amato. Wendy Andrews agreed. “We pre-register all of our patients and verify their benefits.” Her practice requires that patients also verify that they’ve made premium payments. As a result, the front-end administrative burden for providers has increased.
Finally, the panel touched on the impact of narrow networks within marketplace plans. In a rural state, like Maine, “you always worry about access,” said D’Amato. “Creation of narrow networks creates inconvenience for patients.” In Arizona, Andrews said,“the problem we see the most is lack of providers being available in all the plans. What does a patient do when there isn’t a provider in their plan and they have to travel long distances [for care]?”
In summary, the panelists’ described three key challenges post-ACA implementation:
- Access challenges, i.e., having enough providers to meet increased patient demand; narrow networks potentially limiting patient access to providers
- Education challenges, i.e., increased need to help patients, both previously insured and those who are newly insured, understand their coverage and out-of-pocket costs, and
- Front-end administrative burdens, i.e., verifying coverage, understanding patients’ insurance plan coverage, and helping identify resources for underinsured patients.
by Amanda Patton, ACCC Communications
On Tuesday, March 17, at ACCC’s Annual Meeting, Ron Kline, MD, Medical Officer with the Center for Medicare and Medicaid Innovation (CMMI), and Kavita Patel, MD, MS, of the Brookings Institution helped bring a little more clarity to CMMI’s Medicare’s Oncology Care Model (OCM).
The OCM has been developed by CMMI to test new payment and service delivery models, as part of its overarching triple aim of better care, smarter spending, and healthier people. OCM goals center on care coordination; appropriateness of care; and access for beneficiaries going through chemotherapy, Dr. Kline said. Learn more here.
In his overview of the five-year pilot, Dr. Kline pointed to the multi-payer nature of the OCM. “Payers are encouraged to work as part of the model. The point is to leverage the OCM to bring in more and more payers and patients to this model.”
Finally, he stressed the OCM is not intended to be a one-size-fits-all model.
“Part of the point of OCM is that we don’t have all the right answers for all the parts of the country…and the best way to move forward is to learn best practices [through the model].”
CMMI plans to hold webinars, site visits, and meetings at ASCO and elsewhere to share OCM best practices, he said.
So, What’s Everyone Asking?
According to Dr. Patel, the top OCM hot topics are:
# 1 Eligibility. CMMI wants the OCM to “include everyone as much as possible as long as we adhere to the principles of the OCM, attribute, and benchmark appropriately,” said Dr. Kline.
“ACCC is exactly the audience the Oncology Care Model is tailored for—those providing ongoing services for cancer care,” said Dr. Patel.
#2 If you have a practice, can only some providers participate? The short answer is, if you participate, anyone in the practice who is prescribing chemotherapy would be automatically included in the OCM. This includes NPs or PAs who might be prescribing. Simply put: It’s an inclusive model.
#3 Data requirements. Participants need the administrative and technological resources to support these.
For those contemplating OCM participation Patel suggests the following steps:
- Evaluate what infrastructure investment you will need to make.
- Perform a serious “gut check” with providers on what OCM participation will mean.
- Consider how you’ll get all those involved in the OCM to understand the model’s total cost of care framework. (This last item is likely the biggest organizational hurdle, Patel said.)
- Finally, consider the staffing requirements for participation.
What components will be needed for OCM success? Dr. Patel identified three:
- Bringing on primary care physicians
- Learning how to do robust data exchange inside the practice, e.g., having an EMR able to deliver clinicians what they need at point of service
- Being able to predict which patients in your population will need more intensive services (risk stratify).
Perhaps it’s not surprising that even during the OCM discussion, the SGR made a cameo appearance. Dr. Patel noted that details of an SGR fix currently being negotiated on Capitol Hill will likely include some provisions that will force doctors to enter into alternative payment models in the next five years.
ACCC’s 41st Annual Meeting, CANCERSCAPE, kicked off on March 16 with Capitol Hill Day. ACCC members from across the country fanned out across the Capitol for more than 70 scheduled meetings with legislators and key staff members from both the House and Senate.
With the current Sustainable Growth Rate (SGR) patch set to expire March 31, the timing was ripe for these advocates to speak up for a permanent fix to the SGR.
First time ACCC Hill Day participant Linda Gascoyne, patient advocate for medical oncology, East Maine Medical Center in Brewer, Maine, spent the day with the Maine delegation that met with Senator Susan Collins on Monday, afternoon. “I found her [Senator Collins] to be very empathetic as she listened and learned about what we were asking [from Congress],” Ms. Gascoyne said. In addition to the SGR, the Maine delegation talked with Senator Collins about the need for federal oral parity legislation and elimination of the prompt pay discount from the ASP calculation.
Donna Sulsenti, practice manager, South Shore Hematology Oncology and president of HOMNY was part of the New York delegation that had visits with four congressional offices. “It was extremely interesting speaking about issues with our legislators and getting something accomplished,” she said. She also finds it “satisfying to know that ACCC is working for us.”
Another first time ACCC Hill Day participant Monica Cfarku, nurse manager, Oregon Health & Science University, Knight Cancer Institute, said she “learned a lot” from her meetings with hill staff. In turn, she found staff engaged on the issues and interested in learning from her. “I felt like I offered them a different perspective as someone on the frontline of care delivery.” In fact, staff from a congressional office invited her to return later in the week to share more of her perspective.
Stay tuned for more from ACCC’s Annual Meeting, Cancerscape underway in Arlington, Va. Follow us on Twitter at #cancerscape15.
By Leah Ralph, Manager, Provider Economics and Public Policy, ACCC
As ACCC members are well aware, on February 12, the CMS Innovation Center (CMMI) released its much-anticipated Oncology Care Model (OCM) as part of the broader effort to lower healthcare costs and tie reimbursement to quality and value. ACCC has been conducting an in-depth analysis, and, overall, the OCM generally resembles the discussion draft we saw in August; while the model contains many positive elements, other areas still need clarification.
At its core, the OCM looks similar to a patient-centered oncology medical home or accountable care organization (ACO), with a target expenditure and shared savings component that encompasses the total cost of patient care during a particular period of treatment. The model is a voluntary, five-year program slated to begin in spring 2016. Physician group practices, hospital-based practices (except for PPS-exempt hospitals), and solo practitioners that furnish cancer chemotherapy are eligible to participate. Payments will be based on a six-month episode of chemotherapy treatment that is triggered by the administration of a pre-set list of chemotherapy drugs, and will take into account all Part A, Part B, and some Part D expenditures for that patient during the episode. In addition to a FFS payment, providers will receive a care coordination payment to improve quality of care ($160 per patient, per month during the episode) and a performance-based payment to incentivize lower costs that will be based on the difference between a risk-adjusted target price and actual expenditures during the episode. The payment arrangement is one-sided risk, with the option of converting to two-sided risk in the third year.
Importantly, the OCM is a multi-payer model in which commercial payers and state Medicaid agencies are encouraged to participate. Aligning financial incentives by engaging multiple payers will leverage the opportunity to transform oncology care across a broader population. During the selection process, CMMI will favor practices that participate with other payers in addition to Medicare. In addition, practices will have to meet certain quality metrics and undergo practice transformation requirements, including: effective use of electronic health records; 24-hour access to practitioners who can consult the patient’s medical record in real time; comprehensive patient care plans; patient navigators; and continuous quality improvement.
While we were pleased to see much of ACCC’s feedback incorporated in the final version, our dialogue with CMS is ongoing. Our members continue to have questions about the benchmarking methodology, specifics on the quality metrics and practice transformation requirements, eligibility to participate in the model, and more. ACCC will continue to seek answers to these questions, and will offer CMS feedback based on member input.
If your practice is interested in participating, or considering participation, we encourage you to submit a non-binding letter of intent to CMS by the deadline of April 23, 2015. We anticipate CMS will continue to provide additional guidance until the application deadline, which is June 18, 2015.
Join us at ACCC’s Annual Meeting CANCERSCAPE on March 17 and hear directly from Ron Kline, MD, Medical Officer with the Center for Medicare and Medicaid Innovation—an author of the Oncology Care Model, as he shares an insider’s perspective on New Payment and Delivery Models in Medicare.
This week the CMS Innovation Center announced the launch of the Oncology Care Model—the agency’s newest payment and service delivery model, described as a multi-payer, oncology practitioner-focused model designed to improve the quality of cancer care while lowering cost.
According to the CMS announcement, key facets of the model include:
- Episode-based payment that targets chemotherapy and related care during a six-month period following the start of chemotherapy treatment.
- Multi-payer design with Medicare fee-for-service and other payers working in tandem to promote care redesign for oncology patients.
- Requiring physician practices to engage in practice transformation to improve quality and coordination of care.
This is the latest signal that the shift from volume-based reimbursement to payment for value and quality is gaining momentum. The interest in moving healthcare payment away from a system that incentivizes quantity has been reflected in every major healthcare law in recent years—from the Medicare Modernization Act (MMA) in 2003 to the Affordable Care Act (ACA) in 2010.
In fact, the ACA created the $10 billion Center for Medicare and Medicaid Innovation (CMMI) with the sole aim of developing and testing innovative ways to pay providers. And on Feb. 12 the Innovation Center provided its first model for oncology care.
The launch of this model is not unexpected given that in January 2015, for the first time in Medicare’s history, the Department of Health and Human Services (HHS) announced explicit goals for tying Medicare payments to alternative payment models and value-based payments. According to the HHS timeline, 30 percent of all fee-for-service (FFS) Medicare payments will be tied to alternative payment models by 2016—including, but not limited to, Accountable Care Organizations (ACOs), medical homes, and bundled payments for episodes of care. By 2018, 50 percent of payments will be tied to these models. CMS also set a goal of tying 85 percent of traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through such programs as the Hospital Value Based Purchasing or Hospital Readmissions Reduction programs.
The initial benchmark of 2016 sets a laudable, but ambitious, goal. Certainly the announcement signals the Obama Administration is making this issue a priority, and we can expect to see an accelerated push to transition Medicare payments and, in turn, private payers.
This shift is a huge undertaking that will not only affect payments, but fundamentally change incentives for how providers deliver care. Implementation will take time, and will require the right balance of forward momentum and important safeguards to ensure that patients continue to receive the most appropriate, quality care. As HHS moves full steam ahead, the provider community must speak up and urge policymakers to:
- continue to work to find consensus on appropriate quality measures,
- establish a sound, fair methodology for calculating financial benchmarks and risk adjustment, and
- allow providers the time, resources, and flexibility they need to implement these new payment models.
The just-announced Oncology Care Model (OCM) will test the bundling of payments for chemotherapy administration. But with other models, such as the Medicare Shared Savings Program (Medicare ACOs) that are primary care focused, it’s still unclear how oncologists will be included or even participate. Caring for cancer patients is complex and often expensive, leaving inherent challenges in how to account for cancer care in alternative models. How will high-cost drugs and innovative therapies be treated in the construct of an ACO? Will high-cost cancer patients be included in the financial benchmark? What is oncology’s role in shared risk and savings? ACCC and other organizations are continuing to work with CMS to answer these questions.
Call to Action
ACCC encourages the provider community to remain informed and active participants in the policy-making dialogue to ensure that we do, in fact, achieve meaningful, realistic payment reform. One of the best ways to get engaged is meeting with your legislators at ACCC’s upcoming Capitol Hill Day on March 16. The next day, at ACCC’s Annual Meeting, CANCERSCAPE on March 17, we’ll be hearing from Ron Kline, MD, Medical Officer with the Center for Medicare and Medicaid Innovation – an author of the Oncology Care Model. Now is the time to come to Washington D.C. – get your questions answered and voices heard at a pivotal moment for oncology care. Join us!
ACCC’s Improving Care in Gastric/GE Junction Cancers project seeks to better the quality of care for gastric and GE junction cancer patients treated at community cancer programs. This is the second post in an ACCCBuzz blog series focused on issues related to gastric and GE junction cancers.
By Guest Blogger Debbie Zelman, President and Founder, Debbie’s Dream Foundation: Curing Stomach Cancer
Stomach (gastric) cancer is a silent killer with symptoms that are non-specific, or non-existent. Stomach cancer screenings are not available in the United States, so 80% of patients are diagnosed late at stage IV, and only 4% of stage IV gastric cancer patients live for five years after diagnosis. More than 22,000 Americans will be diagnosed this year, and rates are rising among adults aged 25-39, which is of great concern.
I know this because I was diagnosed with stage IV stomach cancer in April 2008, when I was 40 years old. I was the mother of three young children, married to a physician, and a practicing attorney with my own firm. I was healthy, didn’t smoke or drink, exercised, took vitamins, and didn’t have a family history. I had NO risk factors for stomach cancer. I thought I was doing everything right, and then I was told that I had a few weeks to live.
My first thoughts were of my children. I was scared to die and that my three-year-old daughter wouldn’t remember me, and my 10-year-old twins would go through their teen years without a mother. I immediately decided that I was NOT going to let that happen, so I began the fight of my life. I underwent very harsh chemotherapy treatments, lost my hair, got neuropathy, almost lost several nails, spent years in bed, hospitals, and doctors’ offices, and had many painful days.
However, I refused to be another statistic. Soon after I started chemotherapy, a friend connected me to another stage IV stomach cancer patient, who became a huge resource for me. I had so many questions about the cancer journey that only he could answer. The doctors, nurses and other healthcare professionals were not as knowledgeable about the stomach cancer experience as another patient with the same diagnosis as mine.
I was shocked to discover there weren’t many resources for stomach cancer, and that a new stomach cancer drug had not been developed in 30 years. How was that possible?
I realized there was a lot of work to be done to raise awareness, so I began to raise funds for stomach cancer research, and educated patients, families, and caregivers. This was the beginning of Debbie’s Dream Foundation: Curing Stomach Cancer (DDF), which was founded in April 2009 to increase awareness, funding, advocacy, and education.
As the first organization in the United States to fight stomach cancer, we have helped hundreds of patients, families and caregivers in 26 states and 12 countries. We set up the Patient Resource Education Program (PREP) so stomach cancer survivors and caregivers can be matched as mentors to other patients and caregivers with similar cancer stage, biomarker, age, gender, and region.
We host free educational symposia and webinars about stomach cancer treatment, surgery, radiation, side effect management, clinical trials, nutrition, and more, which are available on our website. Our next symposium is on April 18, 2015, and we have webinars each month. We’ve held two Capitol Hill Advocacy Days and have successfully increased federal research funding for gastric cancer by millions of dollars. Our upcoming Advocacy Day is on March 4-6, 2015. We’ve funded three Young Fellowship Awards, totaling $150,000, as these researchers will lay the foundation for future discoveries for stomach cancer treatments.
Debbie’s Dream Foundation: Curing Stomach Cancer is pleased to partner with the Association of Community Cancer Centers on its Improving Care in Gastric/GE Junction Cancers education initiative, which offers tools and resources for community cancer programs across the country.
There are plenty of opportunities to get involved in the fight against stomach cancer. Debbie’s Dream Foundation makes it easy. To learn more about Debbie’s Dream Foundation, our events, and how you can get involved, visit us at www.debbiesdream.org.
Please dream BIG with me to make the cure for stomach cancer a reality. Together we can do anything!
To read about “Effective Practices in Gastric Cancer Programs” and access additional resources on ACCC’s Improving Care in Gastric/GE Junction Cancer project page, click here. Next in the series, perpsectives on caring for patients with gastric and GE junction cancer from a community-based provider.
By Amanda Patton, ACCC Communications
ACCCBuzz is in San Diego this week for the ACCC 31st National Oncology Conference.
On Wednesday, at ACCC’s Financial Advocacy Network Pre-Conference, financial advocates from cancer programs around the country gathered for a one-day session focused on challenges and solutions to helping patients with issues around the costs of care.
Increasingly, the term “financial toxicity” is being used to recognize a potentially devastating side effect of cancer—the financial burden on patients and their families related to the cost of their care.
In 2012, the U.S. spent close to $3 trillion on healthcare, speaker Mark Rukavina, MBA, told attendees. Of this, $328 billion was estimated to have been paid out of pocket (for both uninsured and insured consumers). “We don’t have good cost containment strategies in place,” Rukavina said. As a result, people face out of pocket costs beyond their budgets and are exhausting their savings.
“One of the most troubling effects of financial toxicity is its impact on patients’ care seeking behavior,” he said.
Without question, the last challenge cancer patients need to face is the double whammy of serious health issues and serious financial issues.
Cancer care providers today are often on the front lines, helping patients and their families with financial issues surrounding the diagnosis and treatment of cancer. As ACCC’s 2014 Trends in Cancer Programs survey reveals, 90 percent of respondents report offering financial assistance services to patients, and 84 percent report having a financial specialist on staff.
Key session takeaways for oncology financial advocates include:
- Financial advocates need to know their place in the revenue cycle—barriers can crop up anywhere along the line.
- All patients should be screened for financial issues—coverage and financial assistance needs.
- Conversations about costs should take place early on in the care process.
- A lot of work needs to be done to educate newly insured patients about coverage they are purchasing through the insurance Marketplaces, including assistance in understanding health insurance terminology. For example, many newly insured consumers may not understand the meaning of terms such as “premium,” “deductible,” “co-payment,” and “co-insurance.”
- Metrics are key. Financial advocates should:
-Track out-of-pocket coverage metrics
-Measure results of their work and communicate results internally both to justify the position and show the value of the financial advocate services
-Practice continual learning, staying educated about changes in Medicare, state laws, ACA coverage, and more.
Stay tuned for upcoming ACCC Financial Advocacy Network regional meetings November 6 in Schaumburg, Illinois, and December 9 in Seattle, Washington. Find more resources for financial advocates at www.accc-cancer.org/financialadvocacy.
Prepare to be inspired.
Richard Rossi, the keynote speaker at ACCC’s 31st National Oncology Conference in San Diego, Calif., October 8-10, 2014, will introduce meeting attendees to some of the country’s most gifted teenage researchers who are already changing the future of cancer care.
“With all negative news in healthcare, with all the stress and challenges as a cancer care professional, this will be a wonderful opportunity to hear how young people have fundamentally changed the future of medical care by their interventions,” said Rossi. He co-founded the National Academy of Future Physicians and Medical Scientists, an educational enrichment organization that honors, inspires, and motivates the nation’s most promising future physicians.
“Jack Andracka. He’s 17, but when he was 14 and sitting in his science class, he imagined a way to diagnose pancreatic cancer in stage I,” said Rossi.
According to Jack’s Wikipedia entry, the idea for his pancreatic cancer test came to him while he was in high-school biology class, drawing on the class lesson about antibodies and an article on analytical methods using carbon nanotubes he was surreptitiously reading in class at the time. Afterward, he followed up with more research using Google Search on nanotubes and cancer biochemistry, aided by free online scientific journals.
“At age 15 he contacted 200 professors asking for lab space to test his thesis. One hundred and ninety-nine turned him down,” said Rossi. Finally, he received a positive reply from Anirban Maitra, Professor of Pathology, Oncology, and Chemical and Biomolecular Engineering at Johns Hopkins School of Medicine.
The result of his project was a new dipstick-type diagnostic test for pancreatic cancer using a novel paper sensor, similar to that of the test strip for diabetes. This strip tests for the level of mesothelin, a soluble cancer biomarker, to determine whether a patient has early-stage pancreatic cancer. The test is over 90 percent accurate in detecting the presence of mesothelin.
“Jack is not an anomaly,” said Rossi. “The good news is that there are a whole bunch of young people making a huge difference in cancer research.”
And cancer research is not the only area of oncology that’s engaging tomorrow’s leaders.
Some ACCC-member cancer programs are finding innovative ways to connect with the next generation of oncology professionals–from mentoring future oncology nurses to offering internship opportunities to tapping into the energy and enthusiasm of young volunteers in the community.
Stay tuned to ACCCBuzz for highlight’s from Rossi’s keynote talk, “The Good News About the Future of Medicine,” next Friday, October 10, 2014.
Rossi currently serves as president and executive director of the National Academy of Future Physicians and Medical Scientists. Its mission is to identify, encourage, and mentor students who wish to devote their lives to the service of humanity as physicians, medical scientists, technologists, engineers and mathematicians.
It’s not too late to attend the ACCC National Oncology Conference, learn more here.