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!
The last few months have brought big changes to Washington, D.C. We will ring in the New Year with both chambers of Congress under GOP control, which means the parties are reorganizing and, importantly, the legislative agenda is shifting. While it’s still anyone’s guess whether new leadership will mean less political infighting in 2015, issues like trade, energy, and tax reform are early contenders for potential areas of compromise next year.
The ACA (Affordable Care Act) will also make the top of the political agenda: starting in January, you can count on Republicans to look for every opportunity to take the legs out from under President Obama’s signature achievement. Although full repeal is unlikely, as it would face an all-but-guaranteed presidential veto, expect the new majority to focus their efforts on introducing a series of stand-alone bills targeting the most unpopular provisions of the law.
Predicting the fate of non-ACA healthcare legislation is a tougher call. On the one hand, healthcare fatigue still looms large among legislators, making issues like a long-term fix to the Sustainable Growth Rate (SGR), oral parity, and sequestration more of an uphill climb. On the other hand, new leadership, a renewed vow to work across the aisle, and public dissatisfaction with the status quo are bringing new energy to Congress.
Will 2015 Bring a Permanent SGR Fix?
In 2014 we saw what was arguably the best opportunity in years to finally fix the fundamentally flawed SGR formula. Congress came to agreement on a bipartisan bill that had a relatively low price tag, but in the end could not reach consensus on how to pay for the fix. As a result, the bill never came to a vote and will need to be reintroduced in the new Congress. Still the fact that Congress achieved consensus on policy is a promising sign for 2015. We have now weathered seventeen (17!) “doc fix” patches that, if added together, cost far more than the comprehensive approach lawmakers are considering today. This year’s ACCC Capitol Hill Day is scheduled for March 16, so we will be visiting with our legislators just weeks before the current “doc fix” expires on March 31.
Will We See Federal Oral Parity Legislation?
Passing a national oral parity law continues to be a top priority for ACCC membership. On the state level, oral parity efforts are gaining momentum. To date, 34 states and D.C. have enacted oral parity laws, and several other states are ramping up their grassroots efforts for 2015. Given that an estimated 25 to 35 percent of all oncology therapies in the pipeline will available only in pill form, the need for comprehensive, federal oral parity legislation is increasingly critical to patient access. While state-level legislation remains important, lawmakers need to understand that federal legislation would ensure consistency in oral parity laws across the country and would include plans that fall outside the purview of state regulation.
Will We See Any Relief from the Sequester?
Last year, legislation to exempt cancer drugs from the Medicare sequester gained more than 100 cosponsors. ACCC will be advocating for this legislation to be reintroduced in 2015.
As you can see, 2015 is the year to make your voice heard! Join us for Capitol Hill Day on March 16, and stay for the ACCC 41st Annual Meeting, CANCERSCAPE, which will follow March 17–18 in Crystal City, Va. Read our agenda and register today!
If you have additional questions, or would like to get involved with ACCC advocacy, please contact me at firstname.lastname@example.org.
With election results still rolling in, one thing is clear: the 2014 midterm elections dealt an unequivocal win to Republicans, helping them pick up more than the six seats needed to gain the majority in the Senate, bringing both chambers of Congress under GOP control. While this will mean big changes in leadership and the legislative agenda for the remainder of President Obama’s term, it may have fewer implications for healthcare than many anticipated. Here’s why.
The Affordable Care Act (ACA)
One of President Obama’s signature achievements, the ACA faces little chance of repeal in the remainder of the President’s term. Depending on the election results in Louisiana – the last undecided Senate race – in early December, Senate Republicans will hold 53 or 54 seats, falling well short of the 60 vote super-majority needed to get most things passed in today’s Senate. Even more important, Senate Republicans do not have the two-thirds majority to overcome a presidential veto. This means that even if incoming Senate Majority Leader Mitch McConnell rounds up the votes needed to pass repeal, he will not have enough votes to overcome the President’s all-but-guaranteed veto. In the end, even if Republicans control Congress, we can expect that the ACA will remain largely intact.
So does this mean the entire law is safe? Not exactly. Republicans are already outlining a different strategy, in which they will target individual ACA provisions for repeal or significant modifications. The list includes the 2.3% medical device tax; the employer mandate to provide qualified, affordable coverage; and the ACA definition of a full-time employee as 30 hour/week. We can expect the Senate to take votes to roll back these provisions in the next Congress.
The real fate of the ACA may lie with the Supreme Court. Earlier this year, conflicting rulings came from the Appeals Courts on the legality of providing subsidies to those accessing coverage through the federally-run health insurance exchanges, as the law appears to stipulate that subsidies may only be provided to those in state-based exchanges. The Supreme Court recently announced it would take up the case, and is expected to issue a ruling in June 2015. With the federal marketplace serving 34 states and expected to enroll nearly 11.8 million people in 2016 – an estimated 7.3 million of whom would receive federal subsidies – the Court’s decision could have enormous implications for the success of the law.
Sustainable Growth Rate (SGR)
Last year we saw the best opportunity to permanently repeal the SGR. A bipartisan bill had broad support, and the price tag was (comparatively) low at $138 billion – but Congress could not come together to determine how to pay for it. Instead, Congress passed another short-term patch that will expire in March 2015, which prevented roughly a 24% cut in Medicare physician reimbursement rates for 12 months. In keeping with previous fixes, Congress cut healthcare expenditures to pay for the extension. The Congressional Budget Office (CBO), Congress’ official budgetary scorekeeper, recently re-estimated the cost of the bipartisan legislation at $144 billion over 10 years. This is still considered a bargain by most policymakers, and although we can be hopeful the new Congress will consider the legislation, do not be surprised if another short-term patch is what we’re stuck with; despite an “on sale” SGR fix, offsets continue to be a critical stumbling block.
For more than 18 months providers have faced sequester-mandated cuts to Medicare payments, and more than 10 years remain of the 2% Medicare claims reduction. This year, H.R. 1416, a bill that halts the cuts on reimbursement for cancer drugs, garnered some support, but not enough to pass in either chamber of Congress. Many advocacy organizations will push to have the bill reintroduced next year, but H.R. 1416 will remain difficult to pass as part of any stand-alone healthcare bill. The best chance for a solution will be to attach some kind of fix to a larger bill, such as SGR reform.
A number of other issues may come up in the 114th Congress, including oral parity and prompt pay discounts, but would likely be included in larger healthcare-related vehicles. Stay tuned.
The Association of Community Cancer Centers will host a Capitol Hill day for its members on March 16, 2015. We encourage all of our members to attend this annual event and educate elected officials on these important issues. For more information, please click here.
by Amanda Patton, ACCC Communications
Last week hundreds of cancer care providers gathered in San Diego for the 31st ACCC National Oncology Conference. Over two days, attendees joined in a range of dynamic sessions focused around two track themes: YOUR PATIENTS and YOUR PROGRAM.
A unifying message underlying this year’s conference sessions: Regardless of care setting, oncology care providers are facing the same challenges—new payment models, declining reimbursement, increasing competition, quality demands, rapidly evolving technology, and growing emphasis on patient engagement. To achieve the triple aim of improved quality, reduced cost, and enhanced services, providers will need to work together, collaboratively, across settings and service lines.
For those of you unable to be with us in San Diego, here are some key takeaways from each track.
Takeaways from YOUR PATIENTS TRACK:
- Truly patient-centered care requires conversations. For example, when a distress tool triggers a referral to financial assistance: Is the patient having trouble paying rent? Is the patient unable to pay for medications? Is the patient uninsured? Providers need to have conversations with patients to identify and meet these complex needs.
- Patients and families want to be active participants in treatment decision-making. And, they want a say in how our programs provide services, whether this means ensuring access to financial counselors, developing a patient transportation program, or creating a healing garden for reflection during treatments.
- All cancer programs have a responsibility to conduct community outreach—and we are doing this in a number of innovative ways, leveraging our community resources to reach at-risk and under-served populations.
- Proactive patient education provided before the start of treatment can help improve care and patient adherence to treatment recommendations.
- Patient engagement is key to patient-centered care. This requires on-going conversations between patients and their care providers. Patient portals are an emerging tool with potential to improve engagement and, under Meaningful Use, cancer programs will be required to use them.
- Cancer programs need to find ways to make communication easier for patients—whether it’s through an innovative symptom management clinic, patient advisory councils, patient portals, or other venues.
Takeaways from YOUR PROGRAM TRACK:
- The market place is in a state of flux—hospitals acquiring physician practices; practices coming together to strengthen their bargaining power with payers, while remaining autonomous. No matter what the practice setting, physicians and hospitals will need to work together to meet the growing needs of our cancer patients.
- Patient-centered care is not only a requirement for accreditation; it is the right thing to do for our patients!
- The oncology community is exploring a number of new care models. For example, Oncology Medical Home Models that put the patient front and center. This model is accessible to practices of all sizes. Requirements: being innovative and willing to change—tools are available to help.
- The most successful cancer programs have access to and actively mine data to identify areas for improvement and marketplace differentiators.
- With the growing demand for services and a shrinking workforce, the oncology community will need to explore ways to partner with primary care providers to meet the needs of cancer patients.
Stay tuned for additional session highlights from the ACCC 31st National Oncology Conference.
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.
By Matt Farber, MA, Director, Provider Economics & Public Policy, ACCC
On Sept. 30, the Centers for Medicare & Medicaid Services (CMS) released the first round of Open Payments data to the public. The Open Payments program, which was mandated by a section of the Affordable Care Act (ACA) known as the Sunshine Act, requires drug and device manufacturers to report any payments or transfers of value – such as money for research activities, speaking fees, meals and travel – to physicians and teaching hospitals.
The recently released data is based on five months of payment reports, collected from August through December 2013. CMS continues to collect payment information this year and reporting on all 2014 expenditures is expected sometime next summer.
CMS provided a relatively short window (45 days) during which physicians could register and log in to the Open Payments system, check the accuracy of data reports and, if necessary, dispute any reports that they did not believe to be accurate. Unfortunately, most physicians did not review the reports before public release of the data. In fact, technical glitches with the Open Payments system—approximately one-third of the payment reports had “intermingled data”—caused CMS to shut the system down for several days during the physician data review window. In the face of these technical difficulties, both the American Medical Association and PhRMA urged CMS to delay the public release of the Open Payments data but, as we’ve seen, CMS held firm on the Sept. 30 release date.
What Does This Mean for Providers?
First, ACCC recommends that all physicians log in to the Open Payments system, and ensure that all data reports are accurate. CMS is reporting that 4.4 million payments were made during the second half of 2013, totaling $3.5 billion attributable to 546,000 individual practitioners and 1,360 teaching hospitals. Of the 546,000 individuals, only 26,000 (less than 5 percent) registered in the system, the first necessary step to verifying data reports. In addition, CMS suppressed 40 percent of the Open Payments records released because the agency could not reconcile differences in provider names and numbers reported by industry. CMS expects these data to be corrected in time for the next reporting period.
A yet-to-be resolved issue is what will happen with these data. First, it is important to note, as CMS has, that these payments do not necessarily signal wrongdoing; physicians have relationships with industry for a host of reasons, some of which are critical to advancements in innovative medical therapies and patient care. This glimpse into payments is just that: a limited window into billions of dollars in industry spending. ACCC has also long stated that we do not believe that the Open Payments data will greatly impact patients’ choice of providers. There will certainly be outliers, physicians who have a high dollar figure associated with them (not counting those with research money attributed to them) who may draw the attention of the media. This may be especially true if the same physicians appear with a high Medicare payment figure from CMS’ earlier release of data on Medicare payments to physicians. But for a majority of providers, we predict little impact.
Moreover, ACCC hopes that Open Payments data reporting will not have unintended consequences, such as a chilling effect on participation in clinical research. For example, if providers do not want their name to appear in the data reports, they may no longer participate in industry-sponsored trials, nor will they accept certain publications from industry, important activities to advancements in clinical research and cancer care. In addition, if CMS finalizes its proposed rule on the 2015 Medicare Physician Fee Schedule that included elimination of the exemption for payments made to speakers at CME events, the sunshine reporting may have a negative impact on participation in certain CME programming.
If you are a physician or if you work with physicians who have not yet registered in the system, we highly encourage registering today to ensure the accuracy of the reporting. For more information, click here.
By Sydney Abbott, JD, Manager, Provider Economics & Public Policy, ACCC
Implementation of the Affordable Care Act (ACA) is bringing many changes to the healthcare system, including the establishment of health insurance exchanges and new requirements for insurance coverage.
Health insurance exchanges (also known as health insurance marketplaces) provide an option for patients to purchase health insurance outside of employer-based plans and are a step toward the goal of universal coverage. However, because all plans offered through an exchange must meet minimum health benefits and satisfy other insurance reforms, such as a cap on annual benefits and coverage for young adults, individual plan premiums on the exchanges are often more expensive than patients expect. This could lead–and in some cases, has already led–to missed premium payments.
In the event of a lapsed premium payment for individuals enrolled in a federally facilitated exchange (FFE) plan, the ACA gives patients 90 days to become current on any past payments before insurance coverage is terminated. The ACA replaces all existing state laws with the 90 day rule. The rule applies to all consumers, in all states, who purchase subsidized coverage through the FFE health insurance marketplace.
How the 90-Day Rule Works
Here’s how the 90-day grace period works. After the first premium is made, patients have 90 days to pay the next premium. If the patient doesn’t pay the premium for the second month, the insurer can hold all claims. At the end of the third month, if the patient still has not paid, the insurer may terminate the policy.
Unfortunately, there is one wrinkle in the 90-day rule that is concerning for providers. This issue only applies to those individuals who receive tax subsidies to purchase insurance through the FFE insurance marketplace. In this instance, if a consumer still fails to make a payment after 90 days and his or her coverage is dropped, insurers are not required to pay for claims incurred during the last 60 days of the grace period. This means that if coverage for these patients is dropped for nonpayment, physicians must work directly with the patients to collect payments for the balance incurred during days 31-90 of the grace period.
While this issue only applies to individuals who receive tax subsidies to purchase insurance through the federally facilitated insurance exchanges, providers need to know that patients’ insurance cards will not include information on whether or not the patient is receiving subsidies. Claims unpaid the 31st through the 90th day may be pended by the insurer. If the enrollee never pays his or her share, the claim is not payable by the insurer.
During a recent House Energy & Commerce Oversight and Investigations Subcommittee hearing, insurers were asked about health insurance marketplace enrollment and premium payment by enrollees. Representative Michael Burgess (R-TX) and other subcommittee members expressed concern over the 90-day grace period and the chilling effect it may have on provider participation in exchange plans. Insurance company executives testifying at the hearing assured the subcommittee that adequate systems are in place to give physicians the ability to determine patient payment and eligibility status. Industry representatives said call centers, and in some instances online applications, are available for premium payment verification. However, premium status policies vary by company and so providers and their staff are left with a complex process for determining a patient’s status. At the conclusion of the hearing, the Oversight and Investigations Subcommittee remained concerned that this information is not readily available to healthcare providers who might ultimately be left unreimbursed for care already provided.
ACCC agrees with the concerns expressed by House Energy and Commerce Subcommittee members and urges Congress and the Administration to work together to require more easily accessible and real-time patient status data to be available to providers. ACCC has submitted a letter to the Administration about this issue and continues to work with members of Congress to raise the volume. We will keep members posted on any developments on the 90-day grace period.