ASCO Proposes New Physician Payment Reforms

Robin Zon, MD

ASCO has proposed a series of payment reforms that it says would significantly increase physician pay, improve the breadth of patient services available, and lower the overall cost of cancer care. The reforms build on an oncology payment model ASCO proposed last year as a means of moving from fee-for-service (FFS) care to value-based care.

The Patient-Centered Oncology Payment (PCOP) changes announced Thursday would involve the creation and consolidation of billing codes, while also creating a bundled payment plan that includes hospital admissions, laboratory tests, imaging studies, and treatments.

“With today’s healthcare system in profound transition, it is critically important that payment systems provide medical practices with the flexibility needed to be compensated fairly and adequately, preventing disruption to the care we provide patients and allowing physicians to tailor services to the unique needs of individual patients,” ASCO’s Clinical Practice Committee chair Robin Zon, MD, said in a statement announcing the proposed reforms.

Earlier this year the Centers for Medicare & Medicaid Services (CMS) announced an Oncology Care Model (OCM) through which it hopes improved, lower-cost oncology care would develop with physician participation. ASCO has said that this model aligns with its own version but that physicians should have more latitude to develop models of their own, as long as they meet the goals incorporated in CMS models of care.

On Thursday, ASCO said that the PCOP reforms it proposed can achieve those goals while allowing physicians sufficient independence to manage their practices for better efficiency and patient health outcomes, separate from the confines of CMS-developed alternative payment models, as defined in the Medicare Access and CHIP Reauthorization Act of 2015, signed into law earlier this year.

“We believe that PCOP would qualify as an alternative payment model, thereby helping to advance federal goals for improving the quality and affordability of healthcare,” ASCO President Peter Paul Yu, MD, said yesterday.

ASCO said its proposed payment reforms would hold physicians accountable for controlling spending without causing harm to patients and would address “inadequate payment” for such day-to-day costs as education and support for patients, rapid response for patients experiencing problems during treatment, care coordination with other providers, and support for patients after active treatment ends.

This would be accomplished through three payment approaches, ASCO said.

Under the “basic” approach, oncology practices would receive four supplemental, non-visit based payments to support diagnosis, treatment planning, and care management. Four new payment codes would be created: new patient treatment planning, $750 for each new patient; care management during treatment, $200 each month per patient; care management during active monitoring, $50 each month per patient during treatment holidays and for up to six months after treatment; and participation in clinical trials, $100 per month for each patient while treatment is underway and for six months afterward.

Practices would be accountable under the plan for cutting down emergency department visits and hospitalizations for complications, maintaining appropriate use of drugs and services, and delivering high quality care near the end of a patient’s life, ASCO said.

The second payment approach, called “consolidated,” would boil 58 CPT codes for evaluation & management and infusion down to fewer than 12 codes, ASCO said. The payments would be monthly and would fall into three primary categories: new patient payment; treatment month payment; and active monitoring month payment, ASCO said.

The third, “bundled,” approach would set a target spending level to cover not only oncology services rendered by practices themselves but also hospital admissions, lab tests, imaging studies, and potentially drugs. “Oncology practices would have greater flexibility to redesign the way they deliver care to patients without the restrictions imposed by the fee-for-service system,” ASCO said in its statement.

In her remarks, Zon stated that the ASCO reforms would inject “stability” into cancer care that would ensure that patients get the cancer services they need.

ASCO said the reform plan was developed with input from a diverse selection of practices as well as experts on physician payment and business analysis. Ideas were culled from practices that had been successful in reducing emergency department visits and hospital admissions.

ASCO theorizes that under PCOP physicians would receive significantly more in payments but overall spending on cancer care would decline, since patients would avoid unnecessary treatments, tests, and expensive hospitalization.