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Facts Are Stubborn Things: The Medicare Part B Experiment, a Patient Advocate's Perspective (Part I)

Why this patient advocate is concerned about the newly proposed Medicare Part B model regarding its level of transparency and the evidence.
Further, this portion of the proposal does not appear to be based on any evidence. Rather, CMS is making a troubling assumption that oncologists and other clinicians are basing drug treatment decisions solely on financial incentives—rather than selecting the optimal treatment for each individual patient based on the clinical evidence. Many cancer groups that are opposed to the proposal appropriately argue that no data exist to support CMS’ assumption that changing their payment schema would reduce costs or enhance care. In its March 8, 2016, edition, The Cancer Letter notes the results from a voluntary UnitedHealthcare project with 5 community oncology practices, where removing financial chemotherapy drug incentives actually proved the opposite to CMS’ assumption. When compared with a national fee-for-service payer registry, when the cost difference was analyzed before and after introduction of the payment change, eliminating the chemotherapy drug incentives actually increased the use of chemotherapy. Further, the predicted fee-for-service cost of the cohort based on the registry was projected to be $98.1 million, whereas the total cost was almost a third lower at $64.8 million. 

As the paper concluded, “Modifying the current fee-for-service payment system for cancer therapy with feedback data and financial incentives that reward outcomes and cost efficiency resulted in a significant total cost reduction.” (The emphasis is mine.) Importantly, such savings were generated without impacting quality and without any measureable impact on toxicity.
Despite the fact that the CMS project references “value-based pricing” in the second part of the proposal, the crux of the problem with the ASP portion is that CMS does not appear to include value and quality of care as endpoints, did not engage critical stakeholders in the development of the proposal, and is focusing solely on drug utilization and associated costs.

In Part II of this article, Ms Madden will discuss her concerns from her perspective as a patient advocate regarding the reactions of many stakeholders to the value-based pricing proposed in the CMS Part B Drug Payment Model.

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