Going for Broke: CMS’ Oncology Care Model Comes with a Price

The price of treating cancer has ballooned into a national spending crisis, and it shows no sign of slowing.  In 2011, the national cost of cancer care was $88.7 billion.  Those costs will hit $157 billion by 2020, according to projections.  To reduce cancer-related expenses for Medicare, the Centers for Medicare and Medicaid Services has introduced its new oncology care model, which offers participating physicians financial incentives to reduce patients’ cost of care.

True, something in oncology has to change.  Yet as payers and health care providers submit their applications for the 2016 pilot program, we might consider not just what such a model will save – but what it might cost in the form of a redefined approach to cancer care.

CMS’ Innovation Center, CMMI, envisions the program “provid[ing] higher quality, more highly coordinated oncology care at a lower cost to Medicare.”  Under the program’s design, savings result largely from addressing chemotherapy-related complications outside of the emergency room, thereby avoiding hospitalizations and reducing overall patient expenses.  The pilot is open to payers and health care providers who have submitted letters of intent followed by applications, which are due in June.

In a nutshell, the incentive program works like this: Six-month episodes initiate with a patient’s chemotherapy treatment.  For the duration of the episode, CMS pays physicians a $160 incentive per beneficiary, per month to help with effectively managing and coordinating care.  Physicians can also qualify for an additional cost-sharing incentive.  By comparing per-patient costs during the care episode to the physician’s historical costs for care, CMS calculates which physicians meet the savings margin that qualifies them for the cost-sharing incentive.  The program only includes practices providing chemotherapy.

CMS has reiterated its commitment to bringing “value” to patients through this approach.  They’ve done little, however, to define how such qualitative factors will be measured.  Nor does their approach reflect a crucial distinction: “value” can mean one thing to CMS; another to a patient battling cancer.

Granted, patients do have something to gain from CMS’ approach.  In its effort to minimize avoidable emergency department visits and hospitalizations, it requires physicians to offer round-the-clock care for chemotherapy-related complications.  Such access is good for patients, while the reduced burden for emergency departments helps reduce overall health care expenditures.  The model also encourages integrated care and collaboration among physicians, as they work to reduce spending.

But the model comes with a price: potentially fundamental changes to the nature of cancer care.  Consider how physicians might be affected.  After all, a system that motivates through financial incentives can encourage financial motives.  What about cherry picking patients because the sickest won’t allow for the cost savings that physicians need to achieve?  What about prescribing less expensive drugs even when a newer or more expensive option might work better?

Physicians should be above such tactics, and most are.  But the Oncology Care Model effectively coaches oncologists to act as accountants, tallying costs at every turn.

Beyond asking physicians to prioritize considerations that should rightly be secondary, the model also asks us to control factors that are simply outside our scope.  For example, if a patient breaks a limb or suffers injuries in a car accident, his emergency department costs count against the total care costs calculated by CMS – even though they are not cancer-related.  If the patient sees multiple physicians, oncologists again face the challenge of outside costs.

Finally, and most importantly, we must consider the cost of this system for cancer patients themselves. Will they have access to the medications they need, including breakthrough drugs that carry high price tags?  Will the system reward the values that patients care about, such as quality of life and choice in health care?

And though transparency in cancer care is critical, patients may not respond well to physicians being compensated to keep their costs of care low.  So what becomes of the physician-patient relationship when trust fades?

Indisputably, the United States must deal with crippling cancer costs.  Physicians understand that.  But if we sacrifice the fundamentals – such as patient-centered health care and the physician-patient relationship – I fear we’ll find ourselves on the losing end of this bargain.

Alan Marks, MD, is a Florida oncologist and a member of the Alliance for Patient Access.

Morning Consult