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New Oncology Care Model Released by Center for Medicare and Medicaid Innovation

In the summer of 2014, the Center for Medicare and Medicaid Innovation (CMMI), part of the Centers for Medicare & Medicaid Services, released the framework for a payment model dedicated the care of patients with cancer. Before the release of that framework document and since its release, ASH has been working with the lead staff at CMMI responsible for designing the model to discuss the role of blood cancers within such a model. On February 12, 2015, CMMI revealed the opportunity for practices to participate in this new model. Although there will be additional details to finalize, CMMI would like practices to express interest in participating in the model by April 23, 2015, even though it will not begin paying with this method until 2016.

The framework of the model has changed very little since last summer, but the fleshed-out details make it much more understandable. The payment model has two elements. The first is the payment of a $160 care management fee, triggered by provision of chemotherapy that is paid monthly for a period of six months. The second element is a shared-savings payment opportunity that measures the cost of all patients who are treated with chemotherapy for cancer and compares it to expected costs. If the practice is able to reduce costs more than 4% below the expected amount, the practice will be paid by Medicare an amount that may be as high as the total savings above that 4%. For those familiar with payment reform, the design is reminiscent of an accountable care organization with a more focused patient base. Importantly, expected costs are based on the practice itself, as opposed to the national or regional average costs.

There have been a couple of key questions that have been the subject of ASH’s discussions with CMMI that are detailed below.

Blood cancer costs are often higher and more variable than many of the more common solid tumors. Are they included in this model?

ASH’s discussions with CMMI focused on whether it was appropriate to include blood cancers. The documentation released by CMMI indicates that both lymphoma and leukemia will be included along with other more common cancers such as those of the lung and the breast.

Are genetic variations in blood cancers that can determine treatment taken into account in predicting spending in the model?

The oncology care model adjusts expected costs based on risk factors. However, the risk adjustment in early years can only be done on the basis of existing data, which is limited to data used in the claims process. This means risk adjustment only takes into account demographic information and the diseases as classified in the billing system. There may be some distinction in some areas of blood cancer but it is unlikely to be at the precision level that hematologists may prefer. CMMI has indicated that it wishes to further explore additional data for risk adjustment in the future.

Are patients who receive bone marrow transplants excluded from this model?

All costs that patients undergo in the six months following the initiation of chemotherapy will be included. This means that if chemotherapy is followed by a transplant five months later, those costs would be included.

Drugs are among the highest costs for blood cancer patients. Are they included?

Drug costs are included in the resource costs for the model. One of the issues that ASH and others have identified in previous models that measure costs was a differentiation between costs for drugs administered by a physician and those that are not. Because of the financing mechanism of Medicare, those administered in a physician practice had typically been included as they are covered by Medicare Part B in a manner similar to other healthcare services. Recently, many oral chemotherapy agents have become available through Medicare Part D. These had traditionally not been included. In this model, CMS will include both Part B and Part D costs. This will be complicated somewhat by the fact that not all Medicare patients are covered under Part D plans. ASH plans to discuss more how drug costs are considered but has long advocated for there to be equal consideration of drug costs regardless of the funding mechanism.

What happens if spending is higher than expected?

CMMI gives practices two methods of participating. The first is a one-sided risk model in which there would be no penalty for exceeding expected spending. The second is a two-sided risk model where practices would be penalized for spending beyond expectations. CMMI is attempting to entice practices into the second model by reducing the threshold for sharing savings from 4% to 2.75%.

Will this model encourage physicians to reduce necessary care?

The model includes quality measurement that will be used to adjust the shared savings bonus as well as monitoring of the overall demonstration. If properly designed, these quality adjustments could moderate the risk of this happening. However, ASH will be closely monitoring the demonstration to determine if quality measurements will prevent rewards from substandard care.

Are there any special requirements of the practice to participate?

In order to participate, practices will have to adhere to a set of requirements. Many of these are attestations related to following evidence-based clinical practice guidelines, but there are also a couple of concrete requirements. Notably, patients must have the ability to access the practice at any time and practices must be a current participant in the electronic health record meaningful use program.

Practices owned by hospitals are eligible to participate, with the exception of the eleven dedicated cancer hospitals which are paid under a different Medicare formula.

If you have additional questions regarding the CMMI oncology care model, visit the CMS website or contact Brian Whitman, ASH Senior Manager for Policy and Practice.