CMS Models Shake Up Cancer Care

July 7, 2016

The Centers for Medicare and Medicaid Services’ Oncology Care Model is off and running. As announced during The White House’s cancer summit at Howard University, more than 200 physician practices and 3,200 oncologists have enrolled – effective July 1. But as one value model goes live, another model meets continued resistance. The Senate Finance Committee’s June 28 hearing on the Medicare Part B pricing demonstration gave voice to ongoing concerns about how the experiment could affect care for patients battling cancer and other illnesses.

Oncology Care Model

The Oncology Care Model is a bundled payment program designed to reduce cancer treatment costs while improving patient outcomes.   Seventeen insurance companies have signed on to participate. The White House describes participants as a “geographically, clinically, and organizationally diverse group of practices…[that] care for an estimated 155,000 beneficiaries per year.”

The model breaks cancer care into six-month episodes initiated by a patient’s initial chemotherapy treatment. The model lasts five years, during which practices use national treatment guidelines and incorporate CMS’ feedback data to continuously improve care. Its perks for patients include patient navigators and 24/7 access to health care providers

Patients and advocates have expressed concerns that, by incentivizing cost savings, the program may reduce patient options and limit access to costly but innovative treatments. The American Society of Clinical Oncology introduced its own alternative model, recently updated, in 2015.

Medicare Part B Pricing Demonstration

Among new initiatives in cancer treatment, however, one proposal remains a point of contention. The Senate Finance Committee held a hearing June 28 on CMS’ Part B Payment demonstration featuring dialogue between senators and the FDA’s chief medical officer, Patrick Conway, MD. Senators expressed concerns that the demonstration would reduce patients’ access to medications for which no low-cost generic exists.

They also emphasized what Committee Chairman Orrin Hatch (R-Utah) described as “widespread opposition” to the rule, noting that 300 organizations have written FDA against the demonstration. As noted during a May hearing by the House Energy and Commerce Health Subcommittee, the Part B demonstration took shape without the benefit of stakeholder and patient input. By comparison, CMS elicited feedback from physicians and other stakeholders over a period of three years before formalizing the Oncology Care Model.

Medicare Part B covers drugs that are infused or injected, typically in a physician’s clinic. Phase 1 of the two-phase program could begin as early as fall 2016 by reducing clinicians’ reimbursement for administering Part B drugs. Phase 2 would implement a variety of value-based pricing tactics. Participation in CMS’ demonstration would be mandatory for practices in selected zip codes.

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