Up Next for the Center for Medicare and Medicaid Innovation: Cancer

Ross D. Margulies, JD, MPH; Jayson Slotnik, JD, MPH

May 2014, Vol 5, No 4 - Health Policy


In passing the Affordable Care Act (ACA) in 2010, Congress had as one of its central goals the creation of new, innovative ways of paying for and delivering healthcare services. With this goal in mind, the ACA established the Center for Medicare and Medicaid Innovation (CMMI), which is tasked with developing new payment and service delivery models to “demo” and, if successful, to eventually roll out nationwide. Since 2010, CMMI has focused the vast majority of its efforts on several high-profile demonstrations, including the Pioneer Accountable Care Organization program, and the several initiatives focused on improving care and savings costs for individuals enrolled in Medicare and Medicaid (the “dual-eligible”).

Until now, reforming the way we pay for and deliver cancer care has been on the back burner for CMMI. In late 2013, however, as part of CMMI’s interest in testing new models of care that will focus on specific diseases and patient populations in the outpatient setting (“Specialty Practitioner Payment Model”), CMMI announced a new partnership with the MITRE Corporation to assess specialty payment model opportunities, conduct model simulations, and to ultimately support the development of alternative payment models.

In cooperation with the Brookings Institution and the RAND Corporation, in late 2013, MITRE announced that oncology care was selected as the first specialty analysis in the demonstration because of the high disease burden and high healthcare costs associated with the disease state. In November, MITRE convened an oncology technical expert panel to review alternative payment reform models that are focused on increasing quality and lowering costs in the cancer care space. For the value-based cancer community, a review of the models under consideration by the panel is a rare and helpful insight into the future of cancer care.

The panel’s overall goal is a transition from volume-based reimbursement to payment for episodes of care, with a focus on aligning physician payments with the delivery of high-quality care. With this broad framework in mind, the panel considered a number of models that move away from the traditional fee-for-service (FFS) payment model toward a more coordinated, high-quality cancer care regimen.

Alternative 1: Clinical Pathways
The first model the panelists considered was the clinical pathways model, which uses an add-on case payment to encourage adherence to predefined, evidence-based chemotherapy regimens. Although there was little negative said of this model, there was wide consensus that clinical pathways should only be viewed as a component of another model, because the model alone does not alter the existing FFS payments, and the model lacks a patient-centered focus and a potential for continued savings over time.

Alternative 2: Patient-Centered Oncology Medical Home
The medical home model, which supports changes in processes of care resulting in high-quality care delivery, was viewed by all of the panelists as a likely model to use to transition from the FFS approach toward full-bundled or shared-savings approaches. Members noted that many providers already incorporate elements of this model into their practice, and that although it has the potential to dramatically improve the patient experience, the potential for long-term cost-savings associated with a more bundled or episode-based approach is much less associated with the medical home model.

Alternative 3: Bundled Payments
All of the panelists agreed that some type of bundled payment for oncology is likely in the future, but that a larger, global bundle in oncology would be very challenging to implement as a first step for the Centers for Medicare & Medicaid Services’ (CMS) payment reform. Instead, the panelists recommended the use of narrowly defined bundles for only the most common cancers. The panelists were in general agreement that narrower bundles for common cancers, such as breast cancer and colon cancer, were more likely to succeed, because the diseases contain more discrete treatment regimens with more known costs. The panelists all agreed that there was an immediate need for additional testing of bundled payments in oncology to better build the existing knowledge database.

Alternative 4: Oncology Accountable Care Organizations
One of CMMI’s major focuses, the number of primary care accountable care organizations (ACOs) has surged in recent years. However, improving care for patients with cancer as part of an ACO has proved more difficult because of its reliance on specialized providers and high expense. Few panelists believed that an oncology-specific ACO model would be a good model for CMS to pilot. Instead, panelists indicated interest in participating in accountable cancer care elements as part of a broader ACO framework.

For the broader oncology community, paying close attention to what is happening at the highest level of innovation is critical. The basic goal behind CMMI is to pilot programs through demonstrations and, if successful, roll them out on a much larger national basis.

Staying informed on what CMMI is thinking on oncology care ensures that the oncology community is apprised of what is coming down the pipeline and, most important, has a voice at the table. If you would like to submit comments, MITRE welcomes comments on the ongoing efforts at specialtypaymentreform@brookings.edu.