Medicare ACO cost incentives for potential prescribing shifts in cancer therapies worry stakeholders
To ensure beneficiary access to new therapies and to retain incentives for innovation, the stakeholders have suggested that the CMS adapt the Medicare payment mechanisms already used for new technologies in the hospital setting. Medicare’s hospital payment scheme includes mechanisms for add-on (inpatient) or pass-through (outpatient) payments. They provide payment for new and relatively expensive treatments in their first few years on the market in addition to the reimbursement rate set for their therapeutic category. The system is designed to account for the fact that the CMS does not yet know with certainty how much the new treatment will add to hospital charges and costs. And the extra reimbursement is intended to make it more likely that hospitals can afford to “try out” new technologies while the CMS collects the data on cost and use patterns that will ultimately allow it to develop a more permanent payment level.
The BIO has suggested that the carveout should apply regardless of the healthcare setting and should include drugs and biologics provided in the physician’s office. “Such congruity is necessary to ensure that the policy does not create an incentive to perform procedures in the hospital rather than the physician’s office,” according to the comments.
Quality metrics and warfarin
In comments on other aspects of the proposal, the BIO has recommended that the CMS should establish a process to rapidly update the quality measures used to evaluate ACO performance. The proposal outlines a number of quality measures, including whether patients at risk of serious disease or frail elderly patients are taking drugs for managing chronic disease. The agency also will track patient measurements, such as cholesterol levels and hemoglobin A1c values, to monitor the effectiveness of disease management. The quality measures are expected to improve adherence to drugs for chronic disease.
Nevertheless, the BIO takes issue with the quality metric assessing adherence to warfarin therapy in patients with heart failure and paroxysmal or chronic atrial fibrillation; the concern is that it could discourage the use of newer agents. “This [warfarin] measure already is outdated,” the BIO stated. “There are more advanced therapeutic options available for these patients today as well as additional therapies in development. Leaving the measure in place may force ACOs to use a therapy that is no longer the only clinically appropriate, or even recommended, choice.”
The latest newcomer to the category is dabigatran (Pradaxa). Two other oral anticoagulants are in late-stage development: rivaroxaban (Xarelto) and apixaban. The biotech group’s concerns reflect the tension in the anticoagulant market segment among developers of newer agents and payer concerns over whether the advantages offered by such drugs can justify their increased cost.
A more prominent role for specialists
The ACO proposal is designed to emphasize the role of primary care providers. However, the BIO has advised that the CMS also ensure that specialists play an important part in the operation of ACOs, such as during the development of clinical guidelines and processes. Under the proposed rule, ACOs would be required to “develop and implement evidence-based medical practice or clinical guidelines and processes for delivering care consistent with the goals of better care for individuals, better health for populations, and lower growth in expenditures.”
ASCO echoed the BIO recommendation. “Given the prevalence of cancer in the Medicare community … [the] CMS should require ACOs to secure substantial input from specialists practicing in the community.” ASCO also requested that the CMS ensure that oncology practices do not face undue financial or procedural challenges under the ACO program.
“Oncologists already face a significant form of financial risk arising from the need to purchase and administer chemotherapy drugs within an environment in which Medicare and other health insurers often provide ambiguous coverage policies, payment rates that are inadequate to cover acquisition costs and slow preauthorization decisions,” ASCO stated. Furthermore, ASCO noted that Medicare contractors frequently require “excessive documentation” on the effectiveness of off-label drug indications, even when the indication is supported in the peer-reviewed literature.
