This pledge from Chiquita Brooks-LaSure, MPP, President Biden’s nominee to be the administrator of CMS, is music to the ears of the cancer community.
We interpret it as a strong signal that in her confirmation hearing opening statement, Brooks-LaSure emphasized that she is willing to address serious and growing imbalances in the delivery of medical care in the U.S.
As the Senate voted today to approve Brooks-LaSure’s nomination and she soon begins an immense undertaking, running an agency of 6,000 employees during a stubborn global pandemic, there’s an opportunity to improve how cancer care is delivered. It’s time to transition the delivery of care from expensive mega-hospitals to independent community oncology practices.
Brooks-LaSure should expect that the president will have her back. After all, President Biden headed up the ambitious Cancer Moonshot program during his vice presidency, suffered through losing his eldest son Beau to brain cancer in 2015, and has promised to cure cancer during his time in office. To us, the “cure” starts with the “care.”
No doubt, Brooks-LaSure will be cognizant of the fact that cancer did not shut down like the country did during the pandemic. The National Cancer Institute predicted that in 2020, an estimated 1.8 million new cancer cases would be diagnosed, and that more than 600,000 people would die from the disease. The tragic tidal wave of late stage and missed cancer diagnoses is one that oncologists have been bracing themselves for since new patient numbers cratered last spring at the peak of the pandemic.
Once sworn in, Brooks-LaSure should consider the critical issues to which she alluded in Senate Finance Committee testimony, and some nagging headaches the cancer community has long endured.
Let’s Chart the Future of Oncology Payment Reform, Together
In 2016, the cancer care community welcomed the launch of the Oncology Care Model (OCM) through the CMS Innovation Center. It is by far the largest oncology-focused undertaking we have seen, with the full weight of the federal government behind a monumental shift to value-based care.
Community oncology has embraced the OCM, and practices have invested significant effort to see it succeed. Thanks to that hard work, over the last five years we have learned a lot about how future oncology models must evolve in order for them to be more widely accepted and successful in driving improvement to patient care and value.
What is clear is that in order for bold transformation efforts such as the OCM and its announced successor the Oncology Care First (OCF) model to be successful, they must form collaborative partnerships. Top-down mandated models simply do not work and, in fact, cause enmity.
CMS must continue to collaborate, not mandate. Work with the community oncologists who treat more than half the nation’s cancer patients to shape future payment reform efforts.
Reboot the Radiation Oncology (RO) Model
From radiation oncologists and the attendant care team to group practices and hospitals, a range of stakeholders recognize that the RO Model carried over from the previous administration is fundamentally broken. The new administration needs to redesign this payment model for advance radiation therapy care to focus more on increasing access to care and less on seeking savings.
In a letter to CMS in March, we urged the agency to “provide the radiation oncology community with the data [they] used,” to develop the proposed RO payment model. While those in the cancer community are providers at heart, they also have to deal with the realities of running financially viable businesses and need to plan for the RO Model’s impact and help correct any flaws before it is implemented.
After all, it costs $5.5 million to create a new freestanding radiation oncology center, and an additional $2 million to operate and staff. Among its flaws, the current payment scheme doesn’t factor in, for example, the two standard and concurrent treatments for cervical cancer. Failure to incentivize those treatments leaves a lot of already medically marginalized Medicare seniors with potentially substandard treatment.
Cut Out the Middlemen of American Healthcare
CMS must also identify regulatory solutions to address the counterproductive practices of the pharmacy benefit manager (PBM) industry — the growing bane of cancer patients and their providers.
PBMs, supposedly the insurance industry’s answer for high drug costs, are an oligopoly of rich, vertically integrated companies that routinely prey on local cancer practices and their patients.
Among their abuses, PBMs are allowed to claw back payments from pharmacies weeks after a drug has been dispensed and long after the patient has left the pharmacy. The result, according to the National Community Pharmacists Association — which is suing HHS — is that seniors wind up paying more out of pocket at the pharmacy counter.
PBMs also like to play doctor without a medical license. Documented in media reports ranging from The Atlantic to The Fresno Bee to Medscape, PBMs regularly delay and deny the prescription decisions of oncologists, jeopardizing the health of Americans sick with cancer and concerned about their survival.
Much of the scourge of middlemen will need to be addressed legislatively, but CMS has numerous regulatory levers to address PBMs. One example is enforcing appropriate Medicare quality metrics for oncology pharmacies to ensure patients with cancer are receiving their medications in a timely and appropriate manner.
Keep Up the Pressure on Hospitals
Look no further than the cost of medicines to understand why hospitals are gobbling up medical practices, including oncology practices, like candy.
In a sensational report released on January 15, 2021, Bernstein Research concluded from an analysis on the prices of physician-administered drugs at 30 hospitals, that on average they charge patients more than 2.5 times what they pay for pricey cancer drugs! As a result, the report finds, “Hospitals are incentivized to use more expensive drugs… administering drugs to commercial patients is 20x more profitable than Medicare patients… hospitals markups are responsible in no small part for the high prices experienced by the public.”
While it takes a lot of chutzpah for the hospitals to price-gouge cancer drugs as freely as they have, the Bernstein analysis was a bit hamstrung: data from only 30 hospitals was available. The other hospitals, according to The Wall Street Journal, have violated the spirit of CMS’ price transparency rule requiring them to publish price information.
While CMS faces enormous challenges both in getting important payment models on track and curbing the abuses of the pharmaceutical, hospital, and PBM industries, we look forward to a constructive relationship with Chiquita Brooks-LaSure as she takes over at CMS. The cancer community will be sure of it.
Ted Okon, MBA, is the executive director of the Community Oncology Alliance.