We've been tracking the evolution of new payment models specific to oncology closely on this blog over the past few years and there is a great new proposal I wanted to highlight. Recently, Peter Bach, a well known medical oncologist at Memorial Sloan-Kettering and a former health care advisor during the Bush administration, has published an article in Health Affairs outlining his proposal for an episode-based payment for cancer care for Medicare. Notably, the model he proposes has a very discrete definition of episode, one that would last 4 weeks at time and only include chemotherapy drugs, supportive care (such as anti-emetics) and infusion administration itself. Other services such as diagnostics, imaging, lab etc would not be included. And recognizing that this would be a major change in payment model for medical oncologists, he provides a detailed outline of a potential pilot program, that would essentially phase the episode in over time, allowing for recalibration.
Obviously, this is only a theory - it's no guarantee that Medicare will adopt this as a demonstration project. But as many look to Dr. Bach as a leading thinker in the field, this paper will undoubtedly advance the discussion.
Following our Medicare Reimbursement Update webconference last week, we received dozens of questions about the latest revisions to the physician supervision requirements for hospital outpatient departments. (In case you missed it, access the slides and listen to the recording.) As we didn't have time to answer all of these questions during the call, I wanted to take the opportunity to address them here.
By way of background, the 2011 Hospital Outpatient Prospective Payment System (HOPPS) includes policy changes and clarifications regarding the supervision of therapeutic services delivered in the hospital outpatient setting. While this year's rule does clarify certain aspects of the regulation, it still leaves room for interpretation (see below).
Physician Supervision FAQs
Since the FDA's decision to revoke approval of Avastin for treatment of breast cancer, there has been considerable concern about whether payers will continue to pay for the drug, and consequently, whether breast cancer patients will be able to access it. According to a report in the San Francisco Chonicle, WellPoint, United Health, Aetna and Humana have all indicated that they will continue to reimburse providers for the drug, at least for the time being, based on the NCCN's recomendations.
The article also quotes a spokeman from CMS saying that "most if not all" Medicare contractors will still pay for Avastin for the treatment of breast cancer, at least while appeal of the FDA's decision is pending. The drug's manufacterer, Roche, is expected to file an appeal with the FDA by January 18. The agency has said that it will not decide whether or not to hold a hearing on the appeal until the end of February. One Medicare contractor, Palmetto GBA, had previously announced that it would discontinue coverage of Avastin based on the FDA's decision, but it later reversed its decision.
Insurers Indicate They Will Continue To Cover Avastin for Breast Cancer, For Now