Need for Stakeholder Participation in Developing Payment Models

Ted Okon, MBA: If you look at the CMS (Centers for Medicare & Medicaid Services) and the Center for Medicare & Medicaid Innovation Oncology Care Model (3 years in the making), it involved patient stakeholders and physician stakeholders. You had outside entities like Brookings and MITRE—and I don’t think the lower of cost or market (LCM) is perfect; I have some problems with it.

You can argue that it wasn’t thoughtful, it wasn’t deliberate, it wasn’t comprehensive, and it wasn’t open. We went in and talked to them (CMS) a lot. I sat on a lot of panels with a lot of CMS people—it was very open. Three years in the making.

Then, virtually out of nowhere (we only got a warning because a little notice to contractors was put up), it was taken down after an hour. But, it was air dropped in. You [could] look at it and say, “Where are the outside experts? Where are the patients? Where are the providers? Where are the payers in this? Who was consulting?”

It was nothing. This is what’s called the Medicare Part B Drug Payment Model. I use that term very loosely because that’s very different than the Oncology Care Model—which is a real model. So, we call the former model the Experiment on Cancer Care because that’s exactly what it is; it’s air dropped in. And CMS says, “Well, we’re going to reduce, basically, the multiplier on ASP (average sales price), and we’re going to give you a flat fee.” And by the way, disguised in that is the numbers that they produced. They are not really accurate because there’s a sequester cut on it. So, it’s not ASP + 2.5. It’s ASP + 0.86.

Then, there’s going to be a phase 2 to this that’s going to be about value and this mumbo jumbo. Of course, they don’t have any of that figured out—that’s just justification for calling this a model and, literally, reducing reimbursement.

Bruce A. Feinberg, DO: I’m going to end there. I want viewers to know we’re coming back in a few months, and I think those are exactly the 2 topics we’re likely going to be focusing on. They may be great topics for us to talk about at a future program.

This has been a great discussion today. We’ve reviewed and discussed a lot of information surrounding value-based care in oncology during this Summit. To close, I’d like to ask our panelists for their final thoughts.

James Gilroy: I think this is a representation of how decisions should be made within the healthcare environment—[meaning], with stakeholders like this at the table, first talking about things in concept and sharing ideas. Then, ultimately putting pen to paper.

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