A presentation on legislative and regulatory issues at the recent 37th Annual National Meeting of the Association of Community Cancer Centers (ACCC) in Washington, DC, offered attendees an overview of the changing health-care landscape, and a glimpse of things to come. Speaker Matthew Farber, Director, Provider Economics & Public Policy for ACCC, said that although numerous components of the Affordable Care Act were still in political flux, it is important for the oncology community to start preparing for inevitable reforms such as exchanges, Medicaid updates, high-risk pools, and new payment models and trends in community oncology.

Trends to Watch

Despite efforts by the House of Representatives to stall or kill parts of the Act, the sweeping law still exists and some of the bill’s initiatives have the power to alter the delivery of cancer care. Everyone agrees that exorbitant care spending must be curbed; however, the problem is how to make significant cuts without reducing access or quality. To that end, the administration is studying ways to increase efficiency in our delivery system, such as the creation of Accountable Care Organizations (ACOs).

Mr. Farber said that the Centers for Medicare & Medicaid Services defines an accountable care organization as an organization of health-care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it. “But really, what exactly is an ACO?” asked Mr. Farber. He speculated as to whether an accountable care organization will be a real entity or exist only virtually.

He continued, “There seems to be, even now, a good deal of disagreement on what these proposed organizations will look like and what they will mean to the way we deliver patient care.” The Affordable Care Act states that accountable care organizations will still be paid fee-for-service, but they will be able to “share savings” if they deliver care to Medicare beneficiaries more efficiently.

Proposed Rule Published, Questions Remain

Mr. Farber noted that since his ACCC presentation, the proposed rule for establishing accountable care organizations was published in the April 7 Federal Register, calling for a 60-day public comment period. “Our first goal is to make sure that our members are educated so that if they intend to create or become part of an accountable care organization, they’ll understand the challenges from the business and clinical side,” said Mr. Farber.

“Since ACCC members are both hospital- and physician’s office–based, we are represented across the spectrum of cancer care delivery.  Some members are already prepared to implement an ACO model and may be able to send their applications to CMS as soon as the final rule is published. However, we also have a lot of members with a number of concerns—for one, the very high start-up costs CMS estimates it will take to launch an accountable care organization,” said Mr. Farber.

Mr. Farber mentioned that many oncologists are also concerned about legal issues regarding accountable care organizations. Such issues include contract negotiations and the establishment of network relationships that are responsible for coordinating all aspects of care including the sensitive issue of sharing of patient information.

“In addition to the unanswered questions and logistical issues involved in setting up an accountable care organization, another concern is how the collective aspect of accountable care organizations might shift the site-of-service availability to care for our patients,” said Mr. Farber. He added that  “ACCC is in the process of crafting a comment letter expressing concerns about how accountable care organizations are structured and how the process might affect the delivery of cancer care.”

Comparative (Cost) Effectiveness Research

Another initiative on the oncology community’s radar is comparative effectiveness research, an evaluation instrument purportedly designed to determine the effectiveness of similar therapies or drugs. “Even though we know that cost is not supposed to be part of the comparative effectiveness research discussion, that doesn’t mean that it’s possible to separate out costs from the larger discussion,” said Mr. Farber.

Mr. Farber stressed that ACCC’s overriding goal is to make sure that cancer patients receive the most effective therapy. “We support efforts to determine the most cost-effective therapies, but with the highly personalized nature of oncology, we want to ensure that physicians are not constrained from giving the best care to their patients regardless of cost.”

Another Initiative to Cut Costs

Another cost-control entity of the accountable care organization is the Independent Payment Advisory Board (IPAB) charged with reducing the growth of Medicare spending, ostensibly without affecting coverage or quality. According to Mr. Farber, the initial focus of the Board will be the Medicare Advantage Plan and Prescription Drug Plans.

“Our central concern with the Independent Payment Advisory Board is that it is basically going to be yet another bureaucratic body that is going to suggest cuts to Medicare reimbursement and, unlike members of Congress, the Board is not going to be accountable to our members,” said Mr. Farber.

He continued, “The questions we need answers to are these: What is this Independent Payment Advisory Board going to cut, and who is going to constitute the 15-member board that will be nominated by the President?” Mr. Farber explained that for the first 5 years the Board has specific limitations on what they can cut, but after that pretty much all of Medicare is fair game, including outpatient services and drug reimbursement. “The confirmation process of setting up the Independent Payment Advisory Board will undoubtedly move at a very slow pace, but it is another initiative that ACCC will follow,” said Mr. Farber.

“We are also paying close attention to several other issues that could affect the delivery of cancer care, such as the movement to create new payment systems. Obviously CMS wants to move away from the “buy and bill” payment model that community oncologists depend on,” noted Mr. Farber.

In fact, CMS has been allotted $10 billion over 10 years to study innovation and new ways of paying doctors. Some of the models under review will be episodic care, increased bundling, more use of guidelines, pathways, and benchmarks, and comparative effectiveness research.  “ACCC is working for our members with CMS and Congress, testifying before panels and lobbying for issues that affect our ability to continue to deliver high-value care for our patients,” concluded Mr. Farber. ■

Financial Disclosure: Mr. Farber reported no potential conflicts of interest.