Matthew E. Brow

Within community practice, we are faced with the dual challenge of providing health care and operating a viable business entity. This problem is not unique to oncology; however, the specialty has been unfairly burdened with preferential payment incentives that favor treatment in hospital outpatient departments (HOPDs) over independent community-based clinics. This trend toward HOPD care has caused a shift in the model of delivery of care and remains a problem for those who practice in community clinics. Furthermore, the shift is driving spending for oncology care higher at a time when payers and patients are contending with rising, unsustainable costs. Providers in individual practices who are focused on the daily responsibilities of caring for cancer patients understandably may find it difficult to keep abreast of national policy changes and understand how those changes might affect their ability to take care of patients. The US Oncology Network and the Community Oncology Alliance (COA) are collaborating to interpret this proposed policy change and to make recommendations for improvement to empower community oncologists to comprehend the impact of this policy and to work toward a better outcome. We will present this proposed policy change in 2 parts: first, an analysis of the impact of current policies on community oncology practice, and second, recommendations for proposed changes to ensure balanced payment amounts for delivery of equivalent services and strategic initiatives for value-based cost reduction.

*For PDFs of the full article and related review of 2012, click on the links to the left of this introduction.  

Within community practice, we are faced with the dual challenge of providing health care and operating a viable business entity. This problem is not unique to oncology; however, the specialty has been unfairly burdened with preferential payment incentives that favor treatment in hospital outpatient departments (HOPDs) over independent community-based clinics. This trend toward HOPD care has caused a shift in the model of delivery of care and remains a problem for those who practice in community clinics. Furthermore, the shift is driving spending for oncology care higher at a time when payers and patients are contending with rising, unsustainable costs. Providers in individual practices who are focused on the daily responsibilities of caring for cancer patients understandably may find it difficult to keep abreast of national policy changes and understand how those changes might affect their ability to take care of patients. The US Oncology Network and the Community Oncology Alliance (COA) are collaborating to interpret this proposed policy change and to make recommendations for improvement to empower community oncologists to comprehend the impact of this policy and to work toward a better outcome. We will present this proposed policy change in 2 parts: first, an analysis of the impact of current policies on community oncology practice, and second, recommendations for proposed changes to ensure balanced payment amounts for delivery of equivalent services and strategic initiatives for value-based cost reduction.

*For PDFs of the full article and related review of 2012, click on the links to the left of this introduction.  

Within community practice, we are faced with the dual challenge of providing health care and operating a viable business entity. This problem is not unique to oncology; however, the specialty has been unfairly burdened with preferential payment incentives that favor treatment in hospital outpatient departments (HOPDs) over independent community-based clinics. This trend toward HOPD care has caused a shift in the model of delivery of care and remains a problem for those who practice in community clinics. Furthermore, the shift is driving spending for oncology care higher at a time when payers and patients are contending with rising, unsustainable costs. Providers in individual practices who are focused on the daily responsibilities of caring for cancer patients understandably may find it difficult to keep abreast of national policy changes and understand how those changes might affect their ability to take care of patients. The US Oncology Network and the Community Oncology Alliance (COA) are collaborating to interpret this proposed policy change and to make recommendations for improvement to empower community oncologists to comprehend the impact of this policy and to work toward a better outcome. We will present this proposed policy change in 2 parts: first, an analysis of the impact of current policies on community oncology practice, and second, recommendations for proposed changes to ensure balanced payment amounts for delivery of equivalent services and strategic initiatives for value-based cost reduction.

*For PDFs of the full article and related review of 2012, click on the links to the left of this introduction.  

The Medicare Shared Savings Program (MSSP) will likely be a nonevent for oncology. Initially, many expected that the accountable care organization (ACO) framework implemented through the 2010 Patient Protection and Affordable Care Act’s MSSP would speed up changes that were already in progress, such as intensifying shifts toward hospital employment of oncologists, creating integrated delivery systems in geographic areas, and requiring oncologists either to form their own ACOs or figure out how to plug into established ACOs. Those expectations were quashed, however, after the Centers for Medicare & Medicaid Services (CMS) released its proposed rule for the MSSP (see sidebar), and would-be participants realized how burdensome and proscriptive it would be to implement the program. More important for oncology, under the proposed rule, it seems that the CMS does not intend for the shared savings program to tackle cost-effectiveness in the oncology setting for the following reasons:

• Oncologist-managed patients are not considered in the MSSP and would not be assigned to an ACO (see sidebar);
• Even if oncologist-managed patients were to be included in the MSSP, they would still likely be excluded by the outlier threshold because their treatment and management costs are so high;
• Even if the rules were to be changed to count oncologist-managed patients who exceed the proposed outlier threshold, the CMS approach of inflating historic spending to set future targets would not allow for a dynamic standard of care in oncology, with the new, costly therapies that are likely to emerge over any 3-year window.

The upshot is that the MSSP provides no incentive for oncologist participation in ACOs, and oncologist participation under a system that bases future targets on historic spending would likely result in missed targets and shared loss payments back to the CMS. With the expected rapid growth of the cancer patient population and the high relative costs to Medicare, it is likely that the CMS will consider targeted approaches to value-based reimbursement in oncology outside of the MSSP. Community oncology practices would be better served by preparing for a targeted oncology approach with private payers and the CMS rather than through the one-size-fits-few MSSP....

* For a PDF of the full article, click in the link to the left of this introduction.

The Medicare Shared Savings Program (MSSP) will likely be a nonevent for oncology. Initially, many expected that the accountable care organization (ACO) framework implemented through the 2010 Patient Protection and Affordable Care Act’s MSSP would speed up changes that were already in progress, such as intensifying shifts toward hospital employment of oncologists, creating integrated delivery systems in geographic areas, and requiring oncologists either to form their own ACOs or figure out how to plug into established ACOs. Those expectations were quashed, however, after the Centers for Medicare & Medicaid Services (CMS) released its proposed rule for the MSSP (see sidebar), and would-be participants realized how burdensome and proscriptive it would be to implement the program. More important for oncology, under the proposed rule, it seems that the CMS does not intend for the shared savings program to tackle cost-effectiveness in the oncology setting for the following reasons:

• Oncologist-managed patients are not considered in the MSSP and would not be assigned to an ACO (see sidebar);
• Even if oncologist-managed patients were to be included in the MSSP, they would still likely be excluded by the outlier threshold because their treatment and management costs are so high;
• Even if the rules were to be changed to count oncologist-managed patients who exceed the proposed outlier threshold, the CMS approach of inflating historic spending to set future targets would not allow for a dynamic standard of care in oncology, with the new, costly therapies that are likely to emerge over any 3-year window.

The upshot is that the MSSP provides no incentive for oncologist participation in ACOs, and oncologist participation under a system that bases future targets on historic spending would likely result in missed targets and shared loss payments back to the CMS. With the expected rapid growth of the cancer patient population and the high relative costs to Medicare, it is likely that the CMS will consider targeted approaches to value-based reimbursement in oncology outside of the MSSP. Community oncology practices would be better served by preparing for a targeted oncology approach with private payers and the CMS rather than through the one-size-fits-few MSSP....

* For a PDF of the full article, click in the link to the left of this introduction.

The Medicare Shared Savings Program (MSSP) will likely be a nonevent for oncology. Initially, many expected that the accountable care organization (ACO) framework implemented through the 2010 Patient Protection and Affordable Care Act’s MSSP would speed up changes that were already in progress, such as intensifying shifts toward hospital employment of oncologists, creating integrated delivery systems in geographic areas, and requiring oncologists either to form their own ACOs or figure out how to plug into established ACOs. Those expectations were quashed, however, after the Centers for Medicare & Medicaid Services (CMS) released its proposed rule for the MSSP (see sidebar), and would-be participants realized how burdensome and proscriptive it would be to implement the program. More important for oncology, under the proposed rule, it seems that the CMS does not intend for the shared savings program to tackle cost-effectiveness in the oncology setting for the following reasons:

• Oncologist-managed patients are not considered in the MSSP and would not be assigned to an ACO (see sidebar);
• Even if oncologist-managed patients were to be included in the MSSP, they would still likely be excluded by the outlier threshold because their treatment and management costs are so high;
• Even if the rules were to be changed to count oncologist-managed patients who exceed the proposed outlier threshold, the CMS approach of inflating historic spending to set future targets would not allow for a dynamic standard of care in oncology, with the new, costly therapies that are likely to emerge over any 3-year window.

The upshot is that the MSSP provides no incentive for oncologist participation in ACOs, and oncologist participation under a system that bases future targets on historic spending would likely result in missed targets and shared loss payments back to the CMS. With the expected rapid growth of the cancer patient population and the high relative costs to Medicare, it is likely that the CMS will consider targeted approaches to value-based reimbursement in oncology outside of the MSSP. Community oncology practices would be better served by preparing for a targeted oncology approach with private payers and the CMS rather than through the one-size-fits-few MSSP....

* For a PDF of the full article, click in the link to the left of this introduction.