Opinion articles

Thursday, October 27, 2011

ONLINE FIRST: New ACO Rules Lack Protections for Cancer Care Quality

BY Allen S. Lichter, MD

CEO, American Society of Clinical Oncology


In an effort to reduce federal health care spending by as much as $940 million over the next four years, the Centers for Medicare and Medicaid Services created the Medicare Shared Savings Program that will use a new payment model called accountable care organizations (ACOs) to share in any savings they achieve. Unfortunately, the final rules CMS recently released to govern this program are inadequate to ensure the new delivery model provides high-value, high-quality care to cancer patients. How ACOs will serve those with cancer remains in serious question and ASCO will continue to push for a number of improvements.


CMS Administrator Donald Berwick understands the importance of evidence-based medicine when it comes to improving quality. His highly successful “100,000 Lives Campaign,” begun while he was CEO at the Institute for Healthcare Improvement, significantly improved cardiac care by requiring adherence to evidence-based processes and procedures. In the CMS final rule, however, the number of quality measures that ACOs will have to report on to qualify for bonus payments was reduced from 65 to 33. Of the 33 measures ACOs must report on, only two address cancer screening and none specifically address cancer treatment.



ASCO’s Quality Oncology Practice Initiative (QOPI) is an oncology-specific quality improvement program with more than 100 measures that provide a comprehensive assessment of quality across various diagnoses and domains of care. At any one time, about 20 percent of practices in the United States are engaged in QOPI to assess and continually improve their quality of care. It is crucial that ACOs require meaningful quality measurement to protect against actual or perceived underuse, overuse, or inadequate use of cancer treatments. Rather than attempting to implement cancer quality assessment themselves, CMS should rely on QOPI as the system for oncology quality measurement.


Oncologists should contribute to setting policies and standards for ACOs, but CMS has declined to require specialist involvement in developing evidence-based standards. In addition, to provide the best possible oncology care, ASCO believes CMS should allow voluntary ACOs that focus exclusively on cancer treatment.


Clinical trials also play an important part in ensuring high quality patient care and CMS should take steps to forbid ACOs from discouraging or otherwise impeding participation in clinical trials. However, to date CMS has not taken specific action in this regard.


Cancer is not a single disease but is comprised of more than 100 diseases. The nature of cancer care is complex, multidisciplinary, and changes rapidly as science evolves. CMS must set policy in a way that requires ACOs to comply with evidence-based cancer care, that comports with quality and standards set by experts in the field, and that provides for timely consultation with oncology specialists to resolve disagreement about treatment plans.  This issue was left unaddressed.

ASCO knows that improving quality can lead to better outcomes while at the same time reducing overall costs. Through better coordination of care and adherence to evidence based medicine, ACOs can have a positive impact on both quality and spending. ASCO will continue to push for improvements to the payment model that focus on the needs of cancer patients, including a cancer-specific quality measurement and reporting system within ACOs, oncology-specific delivery models, and unfettered access for patients to oncology specialists and clinical trials. These steps are needed to ensure ACOs provide the best possible care to Medicare patients with cancer.