Tag Archives: value-based payment models

Cooling Down ICER? Five Questions to Consider

By ACCC Communications

Three jigsaw puzzles pieces (sm)Although the value-based reimbursement train has definitely left the station and is picking up speed, those in the oncology community continue to grapple with the thorny issues around understanding and defining value in cancer care. Treatment innovations and costs are driving the value discussion in oncology. New and emerging immuno-oncology therapies, while bringing unprecedented clinical value to many patients, often carry price tags of $100,000 a year or more, and are front and center in these discussions. Patient access in an era of high-priced pharmaceuticals continues to be a major challenge, particularly as many of these innovative therapeutics entail high co-pays and/or co-insurance payments. The result is that some patients face major hurdles to accessing these innovative options.

For those in the oncology community, staying up-to-date on current and proposed value frameworks is essential—not only to advance innovation in cancer care and to ensure patient access to new therapeutic options, but also to protect cancer program economic viability in an era where payment and reimbursement may become increasingly tied to value.

In a recent Institute for Clinical Immuno-Oncology (ICLIO) webinar, a panel of leading experts provided real-world perspectives on value framework development in oncology in the U.S., with a particular focus on the Institute for Clinical and Economic Review (ICER), which has gained prominence in the past 18 months.  For those in the oncology community who may not be familiar with ICER, panelist Jennifer Hinckel, MSc, McGivney Global Advisors, provided background and offered the following five questions to consider in assessing the organization’s recent report related to non-small cell lung cancer (NSCLC):

  • Does ICER have the appropriate expertise to interpret complex clinical data given that there are not disease-specific clinical experts on staff or advisory panels?
  • Does ICER have processes in place to adequately prevent or limit bias or policy/political aims from slipping into its reports?
  • Is ICER’s approach of evaluating products close to the time of approval (or pre-approval) appropriate, given its methodology of including only randomized controlled trial (RCT) data?
  • Does ICER have sufficient staffing to review and update reports in disparate disease areas and to ensure accuracy?
  • Would ICER’s various approaches meet the standards of peer view in a widely published journal?

In a recent op-ed published in the Oncology Business Review, leading lung cancer experts (including ICLIO Advisory Committee Chair, Lee Schwartzberg, MD, FACP) suggest some level-setting principles for value frameworks including the following:

  • Have disease experts as evaluators and authors
  • Have patient-centered endpoints, conclusions, and definitions of value
  • Use rigorous methodologies reflecting evidence-based medicine
  • Apply continuous review and revision
  • Hold peer review and authorship to scientific standards.

Listen to the full ICLIO webinar discussion here.

As noted in a newly-released white paper from the Institute for Clinical Immuno-Oncology, all of the existing first-generation value frameworks have strengths and weaknesses. Each wrestles with defining value, and each exposes inherent tensions between payer concepts of value and the perspectives of patients and providers. As the field of immuno-oncology continues to expand, all stakeholders will need to stay informed and be prepared contribute to ongoing development of value frameworks that consider not only cost and clinical benefit, but patients’ perspectives on value in cancer care.  In the months ahead as the oncology community contributes to the discussion on value determination methodologies in the context of payer negotiations and political pressure to lower costs and enact drug pricing reform, as well as working to ensure access to new and emerging immunotherapy and combination therapies, ICLIO will continue to offer support and resources for the multidisciplinary team serving patients in communities close to home.


ICLIO is an Institute of the Association of Community Cancer Centers (ACCC). In September 2016,  ACCC submitted comments in response to ICER’s national call for proposed improvements to its Value Assessment Frameworks. 

Collision Ahead? Precision Medicine & Cost

By Amanda Patton, ACCC, Communications

meetings-AM2016-brochure-190x246As researchers and clinicians continue to advance our understanding of the genomic and molecular underpinnings of an increasing number of cancers, oncology finds itself at the “perfect intersection of precision medicine and genomics and concerns about cost,” says Kavita Patel, MD, MS, a Senior Fellow at the Brookings Institution and a primary care physician at Johns Hopkins Medicine.

On March 3 at the ACCC Annual Meeting, Cancerscape, Dr. Patel will provide perspective on whether these forces are on an inevitable collision course—or if there may be a way forward to realize precision medicine’s potential to ultimately reduce costs.

Value  =  ?

A core tenet of healthcare reform is transition to a value-based healthcare system. But, as the oncology community is well aware, different stakeholders have different perceptions of “value.”

“Value to some means reduced costs,” says Dr. Patel. “Others define value as reduced costs with increased quality. Arguably precision medicine is the ultimate in value-based care; it aligns the patients’ needs with the most targeted care, however it might have an increased individual cost.”

“Oncology is one of the few areas in medicine where we actually commonly use precision medicine. For example, for lung cancer we routinely send out tissue for targeted genomic screening and have therapies based on the results,”  says Dr. Patel. The challenge is that science continues to outpace policy.

As oncology transitions to value-based payment models, “the members of the same community that brought us precision medicine—cancer clinicians and researchers—must be the ones who define value in precision medicine,” says Dr. Patel.

Population health must be a part of the value discussion, she says. “We have to do a better job of looking at outcomes and metrics and how we are doing with our patients.” Looking ahead, every oncology practice or cancer center will need to be measuring and demonstrating their impact on population health and patient outcomes. Somehow oncology will have to bring  precision medicine’s individualized approach to treatment into alignment with population health value.

The cancer community must have a voice in the value conversation, Patel stresses, “because it’s important that the people who deliver care in real-time be the people who help define value.”

You’re invited to be part of that conversation. Join us at the ACCC Annual Meeting, Cancerscape, March 2-4, in Washington, D.C. Learn more here.

Bringing the Oncology Care Model into Focus

By Leah Ralph, Manager, Provider Economics and Public Policy, ACCC

imagesAs ACCC members are well aware, on February 12, the CMS Innovation Center (CMMI) released its much-anticipated Oncology Care Model (OCM) as part of the broader effort to lower healthcare costs and tie reimbursement to quality and value. ACCC has been conducting an in-depth analysis, and, overall, the OCM generally resembles the discussion draft we saw in August; while the model contains many positive elements, other areas still need clarification.

At its core, the OCM looks similar to a patient-centered oncology medical home or accountable care organization (ACO), with a target expenditure and shared savings component that encompasses the total cost of patient care during a particular period of treatment. The model is a voluntary, five-year program slated to begin in spring 2016. Physician group practices, hospital-based practices (except for PPS-exempt hospitals), and solo practitioners that furnish cancer chemotherapy are eligible to participate. Payments will be based on a six-month episode of chemotherapy treatment that is triggered by the administration of a pre-set list of chemotherapy drugs, and will take into account all Part A, Part B, and some Part D expenditures for that patient during the episode. In addition to a FFS payment, providers will receive a care coordination payment to improve quality of care ($160 per patient, per month during the episode) and a performance-based payment to incentivize lower costs that will be based on the difference between a risk-adjusted target price and actual expenditures during the episode. The payment arrangement is one-sided risk, with the option of converting to two-sided risk in the third year.

Importantly, the OCM is a multi-payer model in which commercial payers and state Medicaid agencies are encouraged to participate. Aligning financial incentives by engaging multiple payers will leverage the opportunity to transform oncology care across a broader population. During the selection process, CMMI will favor practices that participate with other payers in addition to Medicare. In addition, practices will have to meet certain quality metrics and undergo practice transformation requirements, including: effective use of electronic health records; 24-hour access to practitioners who can consult the patient’s medical record in real time; comprehensive patient care plans; patient navigators; and continuous quality improvement.

While we were pleased to see much of ACCC’s feedback incorporated in the final version, our dialogue with CMS is ongoing. Our members continue to have questions about the benchmarking methodology, specifics on the quality metrics and practice transformation requirements, eligibility to participate in the model, and more. ACCC will continue to seek answers to these questions, and will offer CMS feedback based on member input.

If your practice is interested in participating, or considering participation, we encourage you to submit a non-binding letter of intent to CMS by the deadline of April 23, 2015. We anticipate CMS will continue to provide additional guidance until the application deadline, which is June 18, 2015.

Join us at ACCC’s Annual Meeting CANCERSCAPE on March 17 and hear directly from Ron Kline, MD, Medical Officer with the Center for Medicare and Medicaid Innovation—an author of the Oncology Care Model, as he shares an insider’s perspective on New Payment and Delivery Models in Medicare.

Payment Reform—Beyond the Buzzwords

dollarsignby Amanda Patton, Manager, Communications, ACCC

Pay for performance. Bundling. Episodic payments. ACOs. PCMHs. Payment reform buzzwords are now part of the oncology landscape as providers try to envision what the future will look like.

As healthcare reforms move us away from a volume-based payment model toward new value-based models—it’s hard for those on the front lines of cancer care to gauge exactly where oncology is in the transition process.

On April 1, ACCC Annual National Meeting keynote speaker Kavita Patel, MD, MS, will present an insider’s view of the progress to date in the shift from fee for service payment in oncology to quality and value-based models. Dr. Patel is a Fellow and Managing Director in the Engelberg Center for Healthcare Reform at the Brookings Institution.  She has been leading efforts around payment reform in oncology in the private and public sector, including advising the recent Specialty Physician Payment Model Opportunities Assessment and Design (SPPMOAD) project of the Center for Medicare & Medicaid Innovation (CMMI).  Additionally, her current research focuses on payment models in cardiology, gastroenterology, and primary care.  Her knowledge is built on practical clinical experience as a primary care physician as well as her experience serving as a senior advisor to President Barack Obama and the late Senator Ted Kennedy.

In a recent conversation, Dr. Patel gave us a preview of the issues she’ll discuss at the ACCC’s upcoming Annual National Meeting. Read on for a glimpse into how she thinks oncology care delivery may look in the future.

In the near term, Patel believes oncology is likely to experience more pressure to drive down the cost of drugs by forcing doctors not to use high-cost drugs; more pressure for demonstration of adherence to guidelines and pathways; and increasing documentation requirements about patient-reported measures such as pain and symptom management.

Looking further down the road, the many new payment models under consideration make the future a little fuzzier. “Right now in cancer it’s really just fee for service; anything that’s not fee for service would be interesting—ACOs, medical homes, pay for performance, bundled payments, capitation, global budgets,” Patel said. But the move away from fee-for-service is a certainty.

Whatever shape new payment systems take, Dr. Patel thinks it could affect the composition of the oncology workforce. “Our traditional roles might have to be adapted,” she said. “Right now doctors are getting paid to see a lot of patients.” If oncology shifts to value-based payment models, there may be a change in who delivers some patient care. “It might not be doctors and it might not even be nurse practitioners; it may be oncology community health workers.”  Who might fill the role of oncology community health worker? Often these staff are lay persons who can help patients navigate the delivery system and serve as a point of coordination and outreach on the many issues which impact health beyond the four walls of a doctor’s office, such as transportation, housing and nutrition, she said.

Dr. Patel will share more insights and help set the stage for meeting sessions that will provide a deeper dive on topics such as strategies for growth in cancer care delivery, alternate payment models in oncology, the role of physician extenders on the cancer care team, and more at the ACCC Annual National Meeting, March 31-April 2, in Arlington, Virginia.