Policy changes and healthcare payment reform are among the items that will affect the way that cancer patients access care in the near future, said Christin Engelhardt, BS, National Coalition for Cancer Survivorship (NCCS). She reviewed the cancer care landscape with respect to policy and survivorship at the East Coast Regional Meeting of the Academy of Oncology Nurse & Patient Navigators.
Paying for Value
One policy change that may affect patient access to care in the near future is a movement toward paying for value, especially in Medicare, with an emphasis on coordinated care. Fee-for-service is considered to be unsustainable and does not necessarily provide the best care, whereas coordinated care allows for wiser use of resources.
Different models of value have been proposed by a diverse set of stakeholders, including:
- American Society of Clinical Oncology
- National Comprehensive Cancer Network, which has started to release evidence blocks with a value component to its guidelines
- Institute for Clinical and Economic Review
- Payers, including Centers for Medicare & Medicaid Services (CMS), which are testing new payment and service delivery models
Quality measures are becoming increasingly important in the move toward value-based reimbursement models, said Ms Engelhardt, Director of Policy and Advocacy at NCCS. In February 2016, CMS and America’s Health Insurance Plans released 7 sets of clinical quality measures, including 1 on medical oncology.
The Oncology Care Model, developed by CMS, allows CMS to develop new payment and delivery models that are intended to improve the effectiveness and efficiency of specialty care, including oncology. Oncology is the second specialty care model announced by the Center for Medicare and Medicaid Innovation (CMMI).
“The Oncology Care Model encourages participating practices to improve care and to lower costs through an episode-based payment model that financially incentivizes high-quality, coordinated care,” she said. “It’s episode-based, as opposed to the fee-for-service.”
CMMI expects that these improvements will result in better care, smarter spending, and healthier people. Under the Affordable Care Act (ACA), if any model does not meet those goals, CMS must discontinue the model.
There are a number of practice requirements to participate in the Oncology Care Model, including provision of patient navigation. Care planning is another requirement, as is the use of electronic health records.
The Medicare Part B Payment Model proposed by CMS was announced in March 2016; it would change how CMS pays for physician-administered Part B drugs. The latest evolution will be unveiled once CMS considers comments on the proposal. The fate of this proposal is unclear, as some stakeholders have argued that CMMI does not have the statutory authority to implement the model. “This payment model is designed to drive prescribing of the most effective drugs and to test new payment approaches that reward positive patient outcomes,” said Ms Engelhardt. “Whether or not the Oncology Care Model practices would be included has not been decided.”
Growth in Medicare Advantage
Medicare Advantage (MA) plans are growing in popularity. The basic difference between MA and traditional Medicare is that MA provides the beneficiary with more benefits in exchange for a limited provider network, while traditional Medicare places no restrictions on providers. MA can have different designs that can include a copay for a physician visit rather than the 20% coinsurance.
“There are 2 significant differences in MA coverage of which cancer survivors should be aware when considering MA vs traditional Medicare, and that is clinical trials and hospice coverage,” she said.
Under the law, coverage for a Medicare beneficiary who’s in an MA plan reverts to traditional Medicare coverage for the clinical trial. Also, MA plans by law cover the services that original Medicare covers except hospice. When a Medicare beneficiary enters into hospice, those benefits are paid through original Medicare, potentially increasing the cost-sharing burden of beneficiaries in MA plans.
Beneficiaries may get their drug coverage through a stand-alone Part D plan if they have traditional Medicare, or through an MA prescription drug plan if they have an MA plan. All plans, whether a stand-alone Part D plan or an MA prescription drug plan, are allowed to develop formularies and charge coinsurance, deductibles, and copays within CMS policy limits. “Since the Medicare Modernization Act was passed, we have seen more formulary tiers and Part D plans, and more coinsurance requirements as opposed to copays,” she said.
“There is also an increase in utilization management tools such as prior authorization and fail first. Fortunately, Medicare Part D must still cover all or substantially all cancer drugs, so usually, the formularies for cancer survivors are robust, though there still can be some access issues because of the out-of-pocket cost sharing.”
MACRA: Paying for High-Value Care
A new initiative, the Medicare Access and CHIP Reauthorization Act (MACRA), is intended to move toward CMS’s goal of paying for high-value care. It enables healthcare providers to take part in 1 of 2 quality programs: the Merit-Based Incentive Payment System (MIPS) or participation in an Alternative Payment Model (APM). Both MIPS and APMs will go into effect in 2019, but 2017 will be the baseline for measuring and scoring physician performance. MIPS will streamline existing performance reporting programs—the Physician Quality Reporting System, Meaningful Use, and the Value-Based Payment Modifier—into a new performance measurement program in which providers will be evaluated across 4 categories: quality, resource use, advancing care information, and clinical practice improvement activities.
Changes in the ACA
Changes in the ACA for 2017 will include backing off of 2 proposed rules: a tight network adequacy provision and standardized health plan options. With respect to health plan options, a set of standardized options for 2017 exchange plans was approved but is not mandatory.
CMS implemented other rules, one being that services provided by an “out-of-network ancillary provider in an in-network facility” count toward the member’s in-network annual cost-sharing limit.
A recent development in the ACA is an FAQ document on coverage of routine care provided to patients enrolled in clinical trials. CMS ruled that private insurers must cover services that patients would have received outside of a clinical trial, such as an antinausea medication for chemotherapy.
On drug coverage, CMS has issued guidance discouraging plans from placing all drugs used to treat a condition on the highest tier without regard to the cost of the medication. “However, CMS hasn’t yet created a tool for regulators to monitor this and to evaluate whether the benefit designs meet this requirement,” said Ms Engelhardt.
California has led the way on drug coverage, passing legislation that prevents plans from placing all drugs for a condition on the highest formulary tier beginning in 2017. Beginning in 2016, most Covered California customers will not have to pay more than $150 or $250 per prescription per month.
Care Plans and Care Planning
Care plans can improve communication between the cancer survivor and the care team. They can help with treatment decision-making, symptom management, and coordination of care. “NCCS firmly believes a payment reform should support care planning,” Ms Engelhardt said. “NCCS provides many free resources for survivors and professionals on its website, including the Take Charge of Your Cancer Care and the Journey Forward program.”
Payment reforms to support care planning include regulation, alternate payment models such as CMMI’s Oncology Care Model, private payers, and legislation to establish a Medicare benefit.
“NCCS believes that the best legislation to promote care planning is the Planning Actively for Cancer Treatment (PACT) Act,” she said, which was introduced in Congress. The PACT Act would create a Medicare service for cancer care planning and coordination, so providers who are not in the Oncology Care Model, who are paid on a fee-for-service basis, would be able to bill for the time spent creating and talking about the care plan with the Medicare beneficiary. At the end of active treatment, the PACT Act would allow the Medicare beneficiary to receive a survivorship care plan.
Resources for Survivors
Ms Engelhardt ended with a discussion of resources that navigators can provide to cancer survivors to help them become their own advocates.
The Know Yourself Worksheet on the NCCS website helps patients prepare for a visit to their doctor and discuss their preferences with their family and healthcare team. It explores the hopes and goals about diagnosis and prognosis, personal goals and milestones, quality of life during and after treatment, the impact of disease and side effects, and other concerns such as fertility, mobility, and effects of a diagnosis on family and friends.
The Essential Questions to Ask Your Doctor addresses the goals of the treatment, the impact of different treatments on quality of life, clinical trials, and the effects of treatments on daily living. In focus groups, cancer survivors were unanimous about the positive value of the Know Yourself tool, said Ms Engelhardt.
Other resources found on the NCCS website are explanations of cancer care plans and posttreatment care planning, a booklet on employment rights for cancer survivors, and how to become a self-advocate.
Many national, regional, and local support groups are specific to ethnicity.