June 24, 2021 at 5:00 am ET
As Yogi Berra said, “It’s like déjà vu all over again.” An administration gets frustrated that Congress can’t get anything done on drug pricing, so it turns to its vehicle for end-running Congress – the Center for Medicare & Medicaid Services’ Innovation Center – in an effort to change drug pricing.
Created in 2010 as part of the Affordable Care Act, the Innovation Center is supposed to work collaboratively with stakeholders to pilot and test innovative health care payment and delivery models. Demonstration projects, like most clinical research, are supposed to be developed and tested in a small-scale first phase. If deemed successful, they can be modified based on learnings and expanded in a second phase. However, in recent years the Innovation Center has been used in an effort to force wholesale change through large-scale, mandatory programs – not models to be truly tested – that bypass existing laws that Congress passed.
We saw this most recently with President Donald Trump’s proposed “Most Favored Nation Model” and “International Pricing Index Model,” and before that with President Barack Obama’s “Medicare Part B Drug Purchasing Model,” each of which sought to use the Innovation Center to change existing Medicare reimbursement law for a large swath of the country, rather than truly piloting and testing models. Hearing the recent Biden administration drumbeat about the need for mandatory models in the Innovation Center indicates that we’re looking at “déjà vu all over again.”
When an Innovation Center model is mandatory, that means it is being forced on providers who aren’t voluntarily willing to participate because of fears on how it will negatively impact their patients’ care. The fact is that mandatory Innovation Center models are experiments on patient medical treatment, with potentially life-altering and even deadly repercussions in cancer care. Physicians do not want to have the treatment plans they and their patients agree to, based on individual patient needs and scientific evidence, be overruled by bureaucratic “models.”
Seniors with Medicare, especially those in rural and disadvantaged communities, are put in the harrowing position of either participating in a forced government experiment or trying to find another provider, if one is even available. Case in point: The most recent Trump nation-wide mandatory “Most Favored Nation Model” would have resulted in a staggering 19 percent (by his own administration’s estimates) of all Medicare seniors forgoing treatment for cancer and other serious diseases.
The tired, old mantra from health policy wonks is that mandatory models are needed to force providers out of fee-for-service Medicare and into value-based payment arrangements. That is absolutely and demonstrably false in cancer care. Independent community oncology practices are already far down the path to value-based arrangements. The Community Oncology Alliance is tracking 35 oncology payment reform models across the country that practices are currently participating in, including practices that are pioneering risk-based, population health and bundled payment models. Even though the Innovation Center has deemed their current Oncology Care Model a failure, in reality, it has fundamentally improved cancer care in community oncology practices by enhancing the quality of care delivered with a patient-centric focus and lowering costs by keeping patients out of the more expensive hospital setting.
The Innovation Center has the potential to be a force for good in the American health care system, but forcing patients and providers to participate in experiments is not the way to go about it. Nearly four years ago, our team of experts and front-line cancer care providers shared detailed feedback with the Innovation Center leadership on how it can do this, which I will broadly recap here.
First things first, the Innovation Center needs to develop models cooperatively — listening to, and actually acting upon (not just paying lip service to) the input of all stakeholders, including patients and their providers. Second, it needs to expand its focus on models to include Medicare Advantage and commercial payers. Third, the Innovation Center needs to be a nimbler and more communicative organization, particularly during operational models. Participating providers need regular performance feedback in a timely and understandable manner, which is a far cry from what they receive today. Fourth, and perhaps most importantly, the Innovation Center needs to address its Achilles Heel of relying on just analyzing and assessing the impact of models on costs, but instead holistically evaluate the system-wide impact of reform models on patient outcomes, quality of care, and overall costs.
After more than a decade of existence, the Innovation Center is at a crossroads. The Biden administration can refocus the Innovation Center on its congressional charter of truly piloting and testing health care payment and delivery reforms in cooperation with stakeholders, or go down the same old path of “déjà vu all over again” with forced experiments that call into question the return on taxpayer dollars invested in the Innovation Center.
Ted Okon is executive director of the Community Oncology Alliance.
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