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Oncology Times:
doi: 10.1097/01.COT.0000446661.66198.29
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CMS Official Outlines Agency's Strategy to Pay for Tailored, Evidence-based Care

Eastman, Peggy

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WASHINGTON—In an era when cancer treatments are becoming increasingly individualized and expensive, the Centers for Medicare & Medicaid Services' new Innovation Center is taking specific steps to ensure that all patients receive the best individualized care. So said Patrick Conway, MD, MSc, CMS's Deputy Administrator for Innovation and Quality and Chief Medical Officer. This goal is especially important given that payers, including Medicare and Medicaid, increasingly are covering patients for longer periods of time as patients live longer, he said.

In a keynote address at the National Press Club here at the 10th Annual State of Personalized Medicine luncheon hosted by the Personalized Medicine Coalition, Conway said that when the Affordable Care Act established the Innovation Center, some critics immediately viewed it as a cost-cutting measure. “That is not the goal,” Conway emphasized. “We're looking at the long-term effect on patient outcomes. We at CMS do not take cost into our coverage decisions.”

What CMS does engage in, he said, is “a relentless pursuit of improving health outcomes.”

Thus, there may be many individualized treatments that are expensive, but their patient outcomes are better, he said. In that case these expensive, tailored treatments can be considered cost-effective, because even if the initial cost is higher, future treatment costs will be lower if the initial treatment worked.

CMS's Innovation Center has already awarded nearly $900 million for its Healthcare Innovation Awards program, and has committed an additional $900 million.

“The promise of personalized medicine and innovation in our country is amazing, and it's already paying dividends,” he said. But, he stressed, in order to realize that promise, the United States must move away from “a volume-driven, fee-for-service, fragmented system” that is not always tailored to the individual patient. CMS is now working toward transforming the current health care system.

“We need to remove barriers to personalized medicine and catalyze transformation focused on patient-centered care,” he said.

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Away from Fee-for-Service, Toward Population-Based

That transformation of health care, Conway said, will emphasize: clinical efficacy, comparative effectiveness research, and the delivery of high-quality health care reliably and in all settings. The transformation is moving away from fee-for-service and toward population-based care management. Currently, CMS is seeking information about large-scale transformation of physician practices to accomplish its aims of high-quality care and better health outcomes.

“We emphasize value-based purchasing,” said Conway, a goal that stresses quality measurement; aligned payment incentives; use of health information technology, including telemedicine; quality collaborations; continuous learning networks; and the training of clinicians to work in multidisciplinary teams.

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“We are testing new models to improve quality. ... Innovation is happening broadly across the country. Already, Medicare hospital readmission rates are dropping rapidly. This is good news for our country in terms of better care coordination,” he said, adding that hospital-acquired condition (HAC) rates for unwanted mishaps such as ventilator-associated pneumonia are also improving.

PATRICK CONWAY, MD, MSC
PATRICK CONWAY, MD, MSC
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The Secretary of Health and Human Services has the authority to expand promising new models of care delivery tested by the CMS Innovation Center throughout the country, based on the new model's patient-centered quality of care.

Conway cited the following categories of care-delivery models now being tested by the Innovation Center, among others: accountable care organizations (ACOs); bundled payments (a single overall payment for each episode of care related to a patient's illness); and outpatient specialty models such as the medical home—for example, the oncology patient-centered medical home (OPCMH), which has the stated goal to combine evidence-based, individualized care with new technology to create coordinated, patient-centered care, enhance communication on the part of the patient's care team, and reduce unnecessary health resources.

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‘COME HOME’ Project

The Innovation Center awarded the Community Oncology Medical Homes (COME HOME) project $19.8 million to assess a medical home model for Medicare and Medicaid beneficiaries, along with privately insured patients, with newly diagnosed or relapsed breast, lung, or colorectal cancers. The project, which includes seven U.S. community oncology practices, which will provide comprehensive outpatient care and care coordination, relies on evidence-based care pathways, and measures physician adherence to them.

At a recent symposium hosted by the National Coalition for Cancer Survivorship and the American Enterprise Institute (OT 4/10/14 issue), 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, a member of the CMS Oncology Payment Reform Technical Expert Panel, and founder and managing partner of Oncology Management Services Inc., described his positive experience providing high-quality cancer care as a pioneer with the OPCMH model.

Conway cited new diagnostics as critical to the transformation of health care into the individualized, patient-centered system envisioned by CMS. “We want diagnostics that enable tailored therapies,” he said.

He noted that accurate new molecular and genetic diagnostic tests are changing the field of health care, especially in oncology. Companion diagnostics for cancer treatments can provide much benefit to patients: For example, he said, if there were a diagnostic test for sipuleucel-T to determine which advanced prostate cancer patients were most likely to derive benefit from this costly therapy, that diagnostic test would be of much clinical value.

As for CMS coverage decisions, Conway said, “We're trying to be more transparent on how we make coverage decisions. We're getting rid of old coverage decisions that were problematic. I think we're headed in the right direction.”

Over the years, many treatments have been introduced into clinical practice without evidence that they were better than existing therapies. But Medicare has a tool—coverage with evidence development (CED)—in which payers agree to cover new treatments on the condition that manufacturers conduct further studies to support better coverage decisions. CED has been used in cancer for coverage of positron emission tomography (PET) imaging, for example. Medicare expanded coverage for PET scans in cancer care last year.

Conway stressed that CMS is open to working with all stakeholders: “CMS is willing to engage industry, FDA, and other stakeholders on considering the best approach to a myriad of complex issues. We want to work with you.”

Wolters Kluwer Health | Lippincott Williams & Wilkins

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