WASHINGTON — Whether Medicare's oncology demonstration program is a good idea depends on which federal advisory committee you ask.
Members of the Practicing Physicians Advisory Council (PPAC), which advises Medicare officials on issues of concern to physicians, said they think the program—which pays hematologists and oncologists to report on whether they are following practice guidelines in the treatment of patients with certain types of cancer—is a great idea.
Dr. Peter B. Bach, senior policy adviser at the Centers for Medicare and Medicaid Services (CMS), reminded council members that program participants are paid for data submission, regardless of whether the guidelines are being adhered to. “This is not pay for performance,” he said.
Physicians who participate in the demonstration must report on the reason for the patient's visit, the patient's condition, and their use of clinical guidelines to treat the patient. Those who comply will receive an additional payment of $23.00.
Payments for reporting the data are tied to visits for evaluation and management by Medicare beneficiaries with any of 13 different cancers. This is a change from last year, when the payments were tied to chemotherapy visits. CMS also has replaced some of the G-codes used in the 2005 program with new G-codes, and has added 81 new codes, most of which deal with current disease status.
PPAC members said that they liked the program so much that they would like to see it extended to other specialists who treat cancer patients. For example, when it comes to prostate cancer patients, “oncologists are not the appropriate physician to evaluate [the treatment for] that cancer,” said Dr. Peter D. Grimm, a radiation oncologist in Seattle. “I manage prostate cancer almost exclusively; only a very small percentage of prostate cancer patients are seen by oncologists.”
Council member Dr. Barbara L. McAneny, a clinical oncologist in Albuquerque, agreed. “We're the people who find [prostate cancer] when we're looking for other stuff, or see them if they become hormone refractory and are sent on.”
The council recommended that CMS open up the program to include other specialties that “have the primary responsibility for treating the particular types of cancer [involved].”
PPAC Chair Dr. Ronald D. Castellanos, a urologist in Cape Coral, Fla., said this was not the first time the issue of extending the demonstration had been raised. “We went through this last year … and there was lot of discussion about opening the program up to other specialties,” he said. “As I remember, the discussion at that time was, 'This is a program for next year; next year we'll consider it.' You say you want a spectrum of care of each of these disease processes; you're not going to get that by just talking to the oncologist or the hematologist.”
In contrast, members of the Medicare Payment Advisory Commission (MedPAC) said that such demonstration projects should not be used solely to increase payments for oncology services.
Instead, the secretary of the Department of Health and Human Services should use these demonstrations to test innovations in delivery of quality health care, according to MedPAC, which advises Congress on Medicare payment issues. This should result in long-term benefits to both providers and beneficiaries.
The demonstration project has limited the ability of both MedPAC and Congress to assess the impact of payment changes for oncology drugs and drug administration services, said Joan Sokolovsky, a MedPAC senior analyst. “These projects are not budget neutral. They are designed to increase payments to specific specialties,” she said.
If the payment rates aren't accurate, CMS or Congress should address it, she continued. “It should not make payment policy through the creation of demonstration projects.”
MedPAC Commissioner David A. Smith, a senior fellow for business and society with Demos, a research and advocacy organization in New York, thought the demonstration should be scrapped altogether.
“We're spending another $150 million of taxpayer money, and we argue—I think, convincingly … that there's no value from this demonstration.” Other commissioners agreed that the project would increase costs for beneficiaries but not provide foreseeable benefits.
However, some cautioned that pulling the plug might be a premature move.
At press time, MedPAC was preparing to release a report on oncology payment issues to Congress in January, which would include its recommendation on the proper use of demonstration projects.
“By the time our report comes out, [the demonstration] will be a month and a half down the road,” commented Robert D. Reischauer, Ph.D., a MedPAC commissioner and president of the Urban Institute, Washington. “I think the real issue is whether we should provide guidance for 2007 … and say something about ensuring that payments are adequate so you don't have to 'phony' them up with a demonstration.”