Payment Reform Efforts to Support Cancer Care Coordination

The American Society of Clinical Oncology (ASCO) is proposing to profoundly reform payment for cancer care. ASCO's Patient-Centered Oncology Payment: Payment Reform to Support Higher Quality, More Affordable Cancer Care (PCOP) proposal marks a significant step towards value-based reimbursement, fundamentally restructuring the way oncologists are paid for cancer care. The group believes improved quality and reduced spending are possible by providing "sufficient payment" to support a range of typically unreimbursed services, including payment for care coordination and treatment planning based upon appropriate testing. Furthermore, PCOP would meet the criteria of an Alternative Payment Model as defined in legislation Congress enacted in an effort to repeal Medicare's Sustainable Growth Rate formula.

Central to ASCO's proposal is addressing inadequate payment or currently uncompensated time for services critical to managing a complex illness. As part of the basic PCOP model, the workgroup says oncology practices commit to delivering evidence- based care—ensuring patients receive the most appropriate tests and treatments, while avoiding unnecessary expenses. In return, oncology practices receive four supplemental, non-visit-based payments to support diagnosis, treatment planning, and care management. These monthly payments risk reduction if practices fail to adhere to evidence-based guidelines. Services like Evaluation & Management, infusions of chemotherapy, and drug administration in the practice setting will remain billable under the Medicare Physician Fee Schedule. However, for financially more aggressive practices, additional consolidated and bundled payment models are proposed.

ASCO's PCOP expands upon a previous draft payment reform model the group circulated last year and experts say, takes payment reform even one step further than the Centers for Medicare & Medicaid Services' (CMS) Oncology Care Model (OCM). OCM, a multipayer payment and care delivery model, was unveiled by CMS earlier in the year, but was criticized for keeping fee-for-service (FFS) payments in place.

OCM is based on the oncology medical home concept. Like PCOP, OCM would pay oncologists in part on a per-member, per-month basis, with overall payments tied to financial accountability or risk, as well as quality. Participating practices would receive a $160 per-beneficiary payment on top of Medicare FFS payments for a 6-month episode of care. Additional semi-annual performance-based payments would be made for meeting a set of quality measures.The second part of the plan involves shared-savings payments based on benchmark spending targets. The oncology practice can share in the savings achieved, if they reduce costs more than 4 percent below the target price.

Takeaway: ASCO adds its proposals for changing payment for costly oncology services to the increasing number of groups proposing reforms to accommodate the shift to value-based payment systems.