WASHINGTON—As Congress debates physician payment reform legislation, speakers at a meeting here emphasized that whatever form this reform effort takes, it must be truly patient-centered to improve individualized care. Presenters at the meeting—co-hosted by the National Coalition for Cancer Survivorship (NCCS) and the American Enterprise Institute (AEI)—cited the Institute of Medicine's comprehensive 2013 report calling U.S. cancer care “a system in crisis,” and explored how new payment methods could address that crisis and enhance cancer care.
The SGR Repeal and Medicare Provider Payment Modernization Act of 2014 now before Congress is a reform initiative that has bipartisan, bicameral support. The legislative package would repeal the Medicare sustainable growth rate (SGR) formula that governs growth in Medicare spending and move Medicare away from a fee-for-service system. The SGR would be replaced with a merit-based incentive payment system for physicians who meet certain standards, and encourage health professionals to design and test alternative payment models.
“Is there a crisis? Yes, there is,” said Michael Kolodziej, MD, of Aetna, where he is National Medical Director for Oncology Solutions in the office of the chief medical officer. “Oncology care today is just not good enough; it's got to be better. The SGR is the sword of Damocles hanging over every doctor who treats cancer patients.”
‘Major Payment Problems in Cancer’
“I think it's safe to say there are major payment problems in cancer,” said Joshua M. Sharfstein, MD, Secretary of the Maryland Department of Health and Mental Hygiene, former principal deputy commissioner of the Food and Drug Administration, and former commissioner of health for the city of Baltimore. “The way chemotherapy is reimbursed does not make any sense. There are enormous gaps in prevention of cancer and many patients run out of treatment options. What makes this especially frustrating is that there so much scientific progress in cancer.”
NCCS CEO Shelley Fuld Nasso said that the organization supports current Medicare payment reforms, believing that the changes will lead to better patient cancer care planning, clinical coordination, and shared decision-making. “But we do need patients at the table when these discussions on reform take place to ensure that payment reform models are indeed patient-centered,” she emphasized.
The NCCS, an active policy participant, has supported IOM initiatives to identify weaknesses in U.S. cancer and survivorship care, worked to secure Medicare coverage for the routine patient costs incurred in cancer clinical trials, and advocated provisions in the Affordable Care Act to ensure access to health care for cancer survivors.
“I think it really all comes down to the steps that all of us can take to improve care,” said Mark McClellan, MD, PhD, Senior Fellow and Director of the Health Care Innovation and Value Initiative at the Brookings Institution.
“We're seeing a lot of movement away from fee for service; fee for service just isn't very well suited to the kind of personalized medicine cancer patients need,” added McClellan, a former administrator of the Centers for Medicare & Medicaid Services (CMS) and a former FDA commissioner.
New Level of Optimism
Also at the meeting, Rep. Tom Price, MD (R-GA), said he is optimistic that the current payment reform legislation will become law. “There's been a level of cooperation that we haven't seen in a long time,” said Price, an orthopedic surgeon. “I'm hopeful and mildly optimistic… When you have that kind of unanimity it's important to embrace the opportunity.
“It's absolutely vital to have physician leadership on this,” he added. “There are a lot of doctors who have gotten incredibly frustrated with the current system, and understandably so.” These physicians, he said, are saying “Thanks for the memories; I'm moving on.” Their loss to medicine when they do move on represents a “huge intellectual capital loss,” since these physicians are the ones with the most clinical experience and a high level of skill.
Oncology Medical Home
McClellan cited the oncology medical home as a promising new model of personalized cancer care. Agreeing was John Sprandio, MD, Chief of Medical Oncology and Hematology at Delaware County Memorial Hospital, Director of the Delaware County Regional Cancer Center, a member of the Fox Chase Network and the CMS Oncology Payment Reform Technical Expert Panel, and founder and managing partner of Oncology Management Services.
“I really do believe that cancer care is in crisis, and it's pretty late in the game,” said Sprandio, who has pioneered the oncology patient-centered medical home, a cancer care model that combines high-quality, evidence-based patient-centered care with new technology, with the aim of creating efficiency, coordinating care, enhancing communication within the patient's care team, and reducing unnecessary use of health resources.
He said that despite the crisis in cancer care identified by the IOM, he remains optimistic because of payment reform: “Now is the time to do it [payment reform], and do it quickly, to make sure patients are cared for adequately.”
Sprandio noted that the oncology patient-centered medical home (OPCMH) model standardizes the process of cancer care on a foundation of evidence-based guidelines and that “standardization of process acts as a patient safety net—these standards drive consistency.”
Asked in an interview if professional medical societies support the OPCMH concept, Sprandio said, “All the professional societies get it. The biggest barrier would be to get payers to embrace this process.”
Because it is a new concept of care, payers have taken a while to accept the OPCMH, he said, stressing that the model “is reproducible by any practice, and that changes can be made in process regardless of the infrastructure of the practice.”
Sprandio recommended that members of an oncology practice who want to adopt the OPCMH model start with the National Committee for Quality Assurance (NCQA); his oncology practice was the first specialty practice to be recognized by NCQA as a level III patient-centered medical home.
‘Larger and Larger Out-of-Pocket Costs’
He and others at the meeting called Medicare physician payment reform necessary for cancer patients in part because patients are being asked to shoulder larger and larger out-of-pocket costs for their drugs. “Patients are now making decisions not to be treated because of these costs; I can't tell you how distressing it is,” Sprandio said.
Peter Ubel, MD, Professor of Marketing in the Fuqua School of Business and Professor of Public Policy in the Sanford School of Public Policy at Duke University, said, “It doesn't take much before the cost to the patient is catastrophic.” He cited the case of a truck driver with metastatic colorectal cancer who could no longer afford his chemotherapy treatments—a case that is not unusual today.
Any alternative payment models should recognize that “cancer care is a team sport,” said John Cox, MD, a medical staff member of Methodist Hospitals of Dallas (where he is past president of the medical staff) and Editor-in-Chief of the Journal of Oncology Practice. “We've got to develop more of a team approach, and we need a reimbursement system that honors the team.”
Asked by OT if patient-centered alternative payment models could help to respect and carry out cancer patients' wishes about end-of-life care, Cox said yes. “Process standardization is a way of ensuring that end-of-life discussions can occur. When a patient has metastatic cancer, there ought to be a clear discussion of the goals of care in the beginning. In our practice, that has been a challenge—just to have that conversation.”
Cox noted that it is difficult for many physicians to communicate to patients with advanced cancer that they are on a journey that ultimately will take their lives. This kind of communication “is a skill,” he said, adding, “I think we tend to underplay this at our meetings.”
Agreeing with Cox on the need for alternative payment models that include patient-centered discussions on end-of-life care was Lillian Schockney, RN, Administrative Director of the Johns Hopkins Breast Center, Director of the Johns Hopkins Cancer Survivorship programs, Editor-in-Chief of the Journal of Oncology Navigation and Survivorship, founder and program director of the Academy of Oncology Nurse Navigators, and a two-time breast cancer survivor. “It does not take away patients' hope; they may transition to alternative hopes,” such as planning to attend a wedding or living to see the birth of a grandchild, she said.
Some patients with advanced cancer may be undergoing care not because they want it, but because a close family member wants them to have it, she noted. “We need to know our patients well beyond their pathology. We still tend to treat for treatment's sake.”
As for whether physician payment reform will become a reality this year, Rep. Price said, “I wish I could tell you.” Added Kolodziej, “I think we can do it if we put our minds to it.”
Asked by OT at the end of the meeting if they were pleased by the presentations and discussion, Nasso and NCCS Senior Health Policy Advisor Ellen Stovall both said yes. Noted Stovall, “There are a lot of things we need to follow up on, especially in the payment area.”