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Oncology Practice Management - December 2015, Vol 5, No 9 - Reimbursement
Charles Bankhead

Discussions of site-neutrality reimbursement for oncology services have centered on flawed comparisons of Medicare reimbursement methodologies that would deprive patients of the best available care, according to the American Society of Clinical Oncology (ASCO) policy statement (ASCO. J Clin Oncol. 2015 Oct 26. Epub ahead of print).

No basis exists for the view that reimbursement levels for the Medicare Physician Fee Schedule (MPFS) in the office setting and the Hospital Outpatient Prospective Payment System (HOPPS) in the hospital outpatient setting can be substituted for each other. The 2 systems were derived from different data sets, and the Centers for Medicare & Medicaid Services (CMS) established conversion factors unique to each setting.

Instead, a complete overhaul of physician reimbursement is needed to produce a system that supports the entire spectrum of care required by patients with cancer, ASCO leadership said in the policy statement.

“The current systems for reimbursement of outpatient cancer care under Medicare are outdated,” said ASCO President Julie M. Vose, MD, MBA, FASCO, Chief, Oncology/Hematology Division, University of Nebraska Medical Center, Omaha, in a press release.

“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,” said Dr Vose.

“Site neutrality” refers to efforts to reconcile payment differentials for the same or similar healthcare services provided in different settings. The process and methodologies underlying CMS’s establishment of MPFS and HOPPS can result in different payments for similar or identical services, according to the ASCO policy statement.

In an effort to address the payment differences, stakeholders and policymakers have proposed options to establish site neutrality. The Medicare Payment Advisory Commission (MedPAC), members of Congress, and CMS have all proposed strategies to effect site neutrality.

“These site-neutrality proposals are focused on reducing Medicare payment levels in one setting of care without examining whether such modified payments would adequately meet the needs of Medicare beneficiaries with cancer in that setting,” the ASCO panel states. “Policymakers should focus comprehensively on how best to reform oncology policy to support the full scope of oncology services that patients with cancer require rather than jeopardizing patient outcomes by reducing the resources available for patient care on the basis of site neutrality or other narrow analyses.”

Need for Patient-Centered Reimbursement

In contrast to existing payment reform proposals, ASCO supports transition to a patient-centered approach for oncology coding and reimbursement. ASCO and others have developed “transformative models” of reimbursement that focus on the delivery of an expanded set of services that promote efficiency and reduce the odds of avoidable adverse outcomes.

The ASCO panel cites examples of critically important services that are inadequately reimbursed by current Medicare coding and payment levels, including treatment planning, patient education, patient counseling, and coordination of care; social workers, psychologists, and other mental health workers; quality and value improvement and coordination; patient navigators and triage nurses; genetic counselors; nutrition counselors and dietitians; financial counselors; and community outreach.

The panel also calls for special attention to the clinical and financial challenges faced by physician practices and hospitals in low-income areas. Serving low-income communities is more resource-intensive, because patients often have extensive primary needs. Reducing reimbursement for providers in such areas can compromise patient care.

“Commissioners of MedPAC recognized this concern in 2012, concluding that a MedPAC recommendation to reduce payment levels based on site neutrality might create barriers to health care services that did not previously exist for low-income patients,” the panel says.

ASCO’s Recommendations

Consistent with its support for value-­based care, ASCO makes 4 recommendations to achieve a “transformative approach” to Medicare reimbursement. Such an approach would adhere to current best practices for delivering patient-centered care and produce a payment model that focuses on high-quality, high-value care and addresses healthcare disparities. The 4 recommendations include:

  1. Create value-based incentives that improve quality and lower cost
  2. Ensure that physician payment provides adequate support for the full scope of medical and ancillary services required to treat patients with cancer
  3. Continue to study the scope of services that patients require, including specific needs of low-income patients, before implementing changes in payment to oncology practices and hospitals
  4. Transform Medicare coding and payment for outpatient cancer care in a manner consistent with proposals such as those described in ASCO’s model for payment reform, “Patient-Centered Oncology Payment: Payment Reform to Support Higher Quality, More Affordable Cancer Care.”
Private sector initiatives involving transformative strategies have demonstrated significant savings, “perhaps dwarfing any savings derived from traditional site-neutrality initiatives,” the ASCO authors stated.

“Cutting reimbursement levels based on site-neutrality could limit the scope of services available to Medicare beneficiaries across treatment settings,” said Philip J. Stella, MD, Chair of ASCO’s Government Relations Committee, and Medical Director, Oncology Program, St. Joseph Mercy Hospital, Ann Arbor, MI, in the press release.

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Last modified: January 7, 2016
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