Oncology Practices Oppose Mandatory Bundled Payment Model

July 24, 2019 - Implementing a mandatory bundled payment model for radiation oncology oversteps CMS authority and could potentially harm cancer patients, the Community Oncology Alliance (COA) stated in response to a new CMS proposal.

“By their very nature, mandatory models force providers into new models and/or reimbursement of care. These can subject vulnerable patients with cancer and other serious diseases to disruptions in care that they need and are guaranteed and entitled to under Medicare,” COA explained.

“Patients should not be forced into government experiments and tinkering with their health care, especially without physician involvement in the model development and voluntary participation of patients’ providers, who are the guardians of their medical care,” added the non-profit organization representing community oncology practices, which treat the majority of Americans with cancer.

In light of their view on mandatory alternative payment models, COA opposed the bundled payment model proposed by CMS on July 10, 2019. The proposal put forth the Radiation Oncology Model, an episodic payment model for providers and suppliers delivering radiotherapy treatment in certain core-based statistical areas.

COA contended that CMS has no authority to compel providers to participate in compulsory alternative payment model demonstrations through the CMS Innovation Center (CMMI), which was tapped to run the Radiation Oncology model. The group stated:

“It should be noted that mandatory CMMI ‘models’ are not in the charter of CMMI as written into law by Congress. If CMS implements a mandatory model through the CMMI, it must rely on Section 1115A of the Patient Protection and Affordable Care Act for authority to do so. However, according to Section 1115A, the Secretary of the Department of Health and Human Services (HHS) cannot select for testing any model it chooses. Rather, the Secretary is permitted to select for testing only ‘models where the Secretary determines that there is evidence that the model addresses a defined population for which there are deficits in care leading to poor clinical outcomes or potentially avoidable expenditures.’”

Additionally, Congress requires HHS and its agencies to perform a phase 1 test of all CMMI demonstrations to assess care quality, including patient-level outcomes, and changes in spending. Policymakers can waive some statutory requirements in phase 1 testing, but the waiver applies only “as may be necessary solely for purposes of carrying out” the testing in phase 1, COA stated.

Former HHS Secretary Tom Price and several other policymakers at the time made a similar argument in 2016, urging CMS to cease all mandatory demonstrations through CMMI, including upcoming cardiac bundled payment models, which were later canceled before implementation.

A 2018 survey conducted by MGMA also found that 72 percent of medical group leaders opposed any required participation in Medicare alternative payment models.

Making alternative payment model participation voluntary is a more appropriate pathway, the COA explained, because if the model was “reasonable and would advance value-based care, then voluntary provider participation will be robust.”

Furthermore, the group expressed concerns that the mandatory Radiation Oncology Model would interfere with the successes realized under CMMI’s Oncology Care Model (OCM).

Established in 2016, OCM is a multi-payer bundled payment model for physician practices administering chemotherapy to cancer patients. Currently, 175 practices and ten payers are part of the model, and many have seen clinical and financial improvements.

The evaluation of the first six-month OCM performance period showed practices are developing care plans, coordinating care, improving survivorship planning, and improving end of life care, among other efforts to deliver more patient-centered care. Researchers could not find measurable impacts on care quality and cost because of the limited performance period but stated that the initial results are promising.

“[C]areful consideration also needs to be given to how mandatory models will affect the significant investment and progress our country has made in other ongoing quality and value reform projects,” COA stated. “CMS must consider the impact that new mandatory models would have on patients that are already benefitting from the OCM and other ongoing commercial value-based payment models.”

COA recently submitted a new version of the OCM to HHS’ Physician-Focused Payment Model Technical Advisory Committee (PTAC). Titled OCM 2.0, the proposed alternative payment model is another bundled payment model for chemotherapy that more aggressively addresses prescription drug spending.

The group hopes PTAC will approve the model and send it to HHS for a limited scale test.