Providers

Cancer Care in the Crosshairs

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Experts address the impact of impending Medicare Part B policy changes.

June 28, 2016

The federal government is attempting to hand down a raft of changes that will disproportionately affect private oncology practitioners, including changes to Part B drug payment and the ability to dispense Part D drugs. What does CMS hope to achieve by targeting physician practice payment structures and dispensing models? A panel discussion led by AmerisourceBergen Specialty Group president James Frary at ION Solutions' LPP National Meeting, held in April in Orlando, FL, zeroed in on the regulatory issues and policy proposals affecting community oncology practices. As industry experts discussed policy perspectives, a few major themes emerged.

CMS has set its sights on a new payment structure for Part B Drugs.
"If the 'Demo' is successful in the bureaucrats' eyes, then it becomes the law and becomes your payment system."
Joel White
Founder and President
Horizon Government Affairs


The Centers for Medicare & Medicaid Services (CMS) Innovation Center is testing a new payment structure that targets Medicare Part B drugs, including complex oncology therapies administered under close clinical supervision.

Essentially, the government believes the current reimbursement system incentivizes physicians to prescribe higher-priced drugs rather than prescribing treatments that are in the best interest of patients. Based on a concept that originated with the Medicare Payment Advisory Commission (MedPAC) about a year ago, the two-phase plan aims to cut costs and improve patient outcomes and quality of care. Community oncologists who adamantly oppose the endeavor believe the proposed payment structure would drive a wedge between patients and physicians, leading to many unintended consequences.

Community practices are also facing challenges on the Part D front. CVS/Caremark and Express Scripts have recently interpreted CMS Part D regulations to restrict out-of-network in-office dispensing, citing that practices are "closed door," and not community retail pharmacy providers. Additionally, MedPAC is contemplating formulary changes, including modeling formulary management to mirror commercial plans, which would allow plans to change formularies mid-year.

What does it all mean? It could spell trouble for patients. Patient access to community-based cancer care will be at greater risk if physicians can no longer afford to prescribe the most appropriate therapy in their practices. Patients will have to receive treatment in other sites of care, leading to higher patient out-of-pocket costs and program costs. In addition, Part D dispensing restrictions can affect community physicians' ability to monitor patient adherence and outcomes. Together, these policy changes may put the most effective cancer care out of reach for many Medicare patients.

Let's do away with the "Demo." It is an unprecedented and dangerous experiment.
"The government is trying to change clinical decision making based on the assumption that what every oncologist is doing is wrong."
Ted Okon
Executive Director
Community Oncology Alliance

ION Solutions, Community Oncology Alliance (COA) and other organizations have provided comments to CMS expressing concerns that the Demo will lead to many unintended consequences. One of the most salient messages the group wants to get across is that CMS' proposal is structured more like an experiment, not a demonstration as envisioned under the Affordable Care Act.

What makes it look like an experiment? Participation in the "Demo" will be national and mandatory, and CMS plans to randomly assign patients to test and control groups based on zip codes. A typical clinical trial includes patient consent, patient safeguards, quality measures and adverse events reporting. This experiment bears no similarities to a demonstration and offers none of the protections required in clinical trials.

What steps should oncology practices take?
"We have a situation in which they're proposing an experiment that has known consequences, but no known benefits."
Barry Fortner, PhD
President
Oncology Supply


Community-based practices already know how a lower reimbursement rate will affect the segment: it will damage the system, cause a migration of patients to more costly sites of care and may affect access to the most effective drugs. The CMS proposal states that there are no expectations for cost savings in the first phase, and its ability to represent savings in the second phase is unknown.

As CMS continues to review comments on its proposal, COA and other organizations close to the issue urge oncology practices to continue to reach out to House and Senate members, carefully calling the endeavor what it is: an experiment. COA's website houses tools and other resources for practitioners and patients at www.cancerexperiment.org.

A dispensing debate is brewing.
"When you look at the oncology care model, what better way to enhance quality and value than being able to dispense oral oncolytics to our patients on site? It's a no-brainer."
Steve D'Amato
New England Cancer Specialists
Past President, ACCC

Collaboration is the key to pushing back against CMS. The dispensing practices know the value of what they do: they improve care quality, bring better value to patients, reduce costs and eliminate waste. The missing element is data. Recognizing the critical need to partner in collecting and analyzing data, ION Solutions, COA and COPA are developing quality measurement metrics to assist dispensing practices.

Changes to the dispensing model will affect health systems as well, but private practices will shoulder most of the impact. Because health systems purchase drugs at a lower cost, they'd theoretically be able to absorb the hit better than community-based clinics. To block this very real threat to dispensing practices, physicians are urged to get involved and ask their patients to join them in the cause.

Embolden patients to reiterate the message.
"In my 10+ years of patient advocacy, I have not seen a single issue unite patient advocacy groups like the experiment."
Brad Tallamy,
Director, Government Affairs, AmerisourceBergen
Founder, PACT Coalition

The Patient Access to Community Treatment (PACT) Coalition launched a few years ago because the patient perspective was missing as policies affecting community-based care were debated and implemented. When patients communicate the importance of being treated in community oncology practices and what that means for them from a cost and quality of life perspective, it's very powerful.

Whether talking about the experiment or limiting oncology practices' ability to dispense therapies paid under Part D, patients cannot afford the potential changes. Mitigating the impact of these policy proposals will require patients and patient groups to speak out about how such proposals will negatively affect the care they receive.

ION Solutions, a part of AmerisourceBergen Specialty Group, is the largest physician service organization and GPO specializing in the support of community oncology. ION provides technologies, resources and expertise to community-based oncologists to help improve clinical and operational management. Additional information can be found at www.iononline.com. For additional insights and information on advocacy efforts that support the local delivery of cancer care, visit www.communitycountsadvocacy.org.

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