A plan to finally replace Medicare’s much-maligned sustainable growth rate (SGR) payment formula could be unveiled by this summer, federal lawmakers said at a committee hearing. “Here’s the bottom line: If we get to December and we’re doing an extension, that’s a failure on our part,” Rep. Michael Burgess (R–Tex) said at the hearing. “We need a permanent solution that’s predictable, updatable, and reasonable for this year—and nothing else will do.”
“Whatever virtues the SGR had when it was created 14 years ago..., it’s clear that they have vanished,” added Rep. Henry A. Waxman (D–Calif). He noted that in the past 2 years, Congress has had to pass legislation six times, blocking fee cuts of up to 21% or more.
About 30 medical associations, including the American Society of Clinical Oncology (ASCO), responded to the House subcommittee’s request for suggestions and proposals in developing a new system. On May 5, 2011, House subcommittee members met with a five-person panel of experts from medical associations and health policy organizations to consider alternatives to the current SGR formula, which some participants labeled as anything but sustainable.
One size won’t fit all
Although the details of ASCO’s plan and others vary, they also show a consensus on several fronts: repealing the SGR, moving away from the traditional fee-for-services payment model, and providing a 4- to 5-year transition period during which providers can experiment with a variety of payment systems.
In a letter accompanying the ASCO recommendations, the president, Dr. George Sledge, and CEO, Dr. Allen Lichter, stressed that SGR reforms in general should be linked to existing “robust” systems that promote evidence-based medicine. For oncology in particular, that effort should leverage the Quality Oncology Practice Initiative (QOPI), a comprehensive, field-tested program that more than one-quarter of outpatient oncology practices in the United States already participate in. More than 80% of oncology care is provided in that setting.
“The current SGR system has created an uncertain and unstable environment—a situation that threatens the viability of practices and access to care for thousands of cancer patients,” they concluded.
In its recommendations, ASCO asserted that evidence-based medicine is “both warranted and necessary” because:
- Medicare beneficiaries account for more than half of all new cancer diagnoses in the United States, and treatment and prevention of the disease comprise almost 10% of costs under fee-for-service Medicare;
- The care is complex, treatment can span many specialties, and treatment strategies change rapidly to keep pace with scientific advances; and
- These complexities would not be adequately addressed if a multispecialty system (such as the Physician Quality Reporting System) were to be applied in the oncology setting. The recommendations also detailed why the QOPI should be incorporated as the primary quality measurement program: 25%-30% of a range of practices—urban, rural, community, and academic—participate in it; it is free; some private insurers have adopted incentives for participation in the program; the performance measures are field-tested and up-to-date; and participation promotes high-quality, high-value care and can help identify and address discrepancies in oncology care.
Moreover, QOPI “protects the best interests of patients, reduces exposure to unnecessary treatments and tests, minimizes the use of suboptimal treatment options, promotes the coordination of care, and protects the Medicare program from costs associated with poor-quality care,” ASCO asserted in the recommendation.
Members of the expert panel also stressed the importance of avoiding a “one-size-fits-all” solution. “We should [be mindful] that what will work in one part of the country will not work in another part of the country, and that’s why we have continued to talk about a variety of options,” said Dr. Cecil Wilson, president of the American Medical Association (AMA). “There is a temptation to feel that we ought to figure out one rule ...that solves it all.”
Dr. Wilson pointed to the provisions in the Affordable Care Act that allow for a variety of models of accountable care organizations, embodying the concept of options in the medical system. In that spirit, he said that the AMA has formed a physician leadership group to evaluate the effectiveness of alternative payment methods.
Dr. Roland A. Goertz, president of the American Academy of Family Physicians (AAFP), noted in written testimony to the committee that “the evidence shows that to achieve the savings Congress is looking for, and to improve the quality of health care delivered to millions of patients in the country, reform must include investment in primary care.”
To strengthen primary care’s role in Medicare, the AAFP backs payment reforms that would boost primary care reimbursement and support the concept of the patient-centered medical home (PCMH). The AAFP’s proposal would create a blended reimbursement system for primary care delivered within a PCMH: fee-for-service payments and pay for performance, plus care management fees for PCMH-related activities that do not involve direct patient care.