ASCO recently called for comprehensive physician payment reform to support the full scope of services required by patients with cancer, rather than jeopardizing patient outcomes by reducing the available resources in a particular cancer care setting in an effort to achieve “site neutrality” in reimbursement for oncology services. In a new policy statement on site-neutral payments in oncology, published in the Journal of Clinical Oncology (JCO), ASCO asserted that the traditional approach to physician payment under Medicare is flawed and reflects a narrow and outdated view of the needs of individuals with cancer and the best available options for delivering high-quality, high-value care.
Site Neutrality
According to ASCO, current discussions on site neutrality—the concept of providing equal reimbursement for the same services delivered in any care setting—have centered on a flawed comparison between outpatient cancer treatment settings. ASCO contends that there is no basis to conclude that the reimbursement levels developed for oncology services under the two dominant Medicare reimbursement methodologies for outpatient oncology services—the Medicare Physician Fee Schedule and the Hospital Outpatient Prospective Payment System—should be substituted for one another. The two Medicare reimbursement systems, for the physician office setting (Medicare Physician Fee Schedule) and for the hospital outpatient setting (Hospital Outpatient Prospective Payment System), are based on different data sets for rate setting, explained the society in its “Policy Statement on Site-Neutral Payments in Oncology.”
The differences between Medicare Physician Fee Schedule and Hospital Outpatient Prospective Payment System are further exacerbated, in ASCO’s view, by separate conversion factors established by the Centers for Medicare & Medicaid Services under rules that are unique to each care setting. The conversion factors for the two settings are established in different ways that have little relationship to each other or to the actual cost of providing oncology care to Medicare beneficiaries, as they are based on the aggregate amount of Medicare funding allocated for each setting of care for a particular year.
“Given these variables and challenges, there is no reasonable rationale for concluding that reductions are warranted in the payment levels for either setting of care on the basis of payment levels established for the other setting,” according to the statement authored by the ASCO Site-Neutrality Working Group.
“The current systems for reimbursement of outpatient cancer care under Medicare are outdated,” said ASCO President Julie M. Vose, MD, MBA, FASCO. “Alternative payment models that shift the emphasis away from face-to-face office visits and administration of intravenous anticancer drug regimens and toward providing patients with high-quality, high-value oncology care are needed in order to provide the full scope of oncology services to all Medicare beneficiaries, regardless of where they are treated.”
A number of stakeholder groups are working to improve cancer care by developing alternative models for coding and reimbursing oncology services under Medicare. Models developed by ASCO, the Center for Medicare & Medicaid Innovation, and other groups are designed to transform the outdated Medicare oncology coding and reimbursement systems by establishing episode-based or bundled payments that include coverage and adequate reimbursement for the many critical cancer care services that are unrecognized, uncompensated, or undercompensated under the current system. An expanded set of professional services will promote efficiency and reduce unplanned hospitalizations and emergency room visits, noted ASCO. By providing adequate resources to oncology practices for the full scope of medically necessary services, these new models take a patient-centered approach to promoting value and improving patient outcomes, with the promise of lower aggregate Medicare expenditures.
“Private payer initiatives have demonstrated that even greater cost savings can be achieved by transforming and improving the oncology care delivery model compared with traditional site-neutrality initiatives,” said Philip J. Stella, MD, Chair of the ASCO Government Relations Committee. “Conversely, cutting reimbursement levels based on site-neutrality could limit the scope of services available to Medicare beneficiaries across treatment settings.”
Recommendations
Given the move across medicine toward providing value-based care, ASCO recommends a transformative approach to Medicare reimbursement that embraces currently accepted best practices for delivering a patient-centered oncology payment model focused on providing high-quality, high-value cancer care, while also addressing disparities. ASCO’s specific recommendations include:
- Creating value-based incentives that raise quality and lower cost rather than arbitrarily cutting payment levels based on the site of care.
- Ensuring that payment levels for physician practices provide adequate support for the full scope of medical and ancillary services required to treat individuals with cancer.
- Engaging in additional study of the full scope of services required by patients with cancer, including the specific needs of low-income individuals, before implementing any change in resources paid to oncology practices and hospitals.
- Transforming Medicare coding and payment for outpatient cancer care by implementing policies that are consistent with proposals such as ASCO’s “Patient-Centered Oncology Payment: Payment Reform to Support Higher Quality, More Affordable Cancer Care” (PCOP) model.
To read the full statement in JCO, go to http://jco.ascopubs.org/content/early/2015/10/23/JCO.2015.64.0615?et_cid=36883959&et_rid=466246220&linkid=here. ■
