ASCO Against Site-Neutral Payments, Offers Alternative

Megan Brooks

October 28, 2015

"Site neutrality" ― the concept of providing equal Medicare reimbursement for the same services delivered in different care settings, such as offices or hospitals ― is "flawed" and reflects a "narrow and outdated view" of the needs of today's cancer patients, the American Society of Clinical Oncology (ASCO) said in a policy statement released this week.

"Furthermore, it is not consistent with the broad movement in medicine toward value-based reimbursement for all care ― regardless of setting," the ASCO Site-Neutrality Working Group writes in the statement, which was published online October 26 in the Journal of Clinical Oncology.

"The best approach to achieving appropriate payment for all sites of care is to design a payment system that better reflects modern oncology practice. ASCO has developed a proposed model and is actively promoting it to both public and private payers," Philip J. Stella, MD, chair of the ASCO Government Relations Committee, told Medscape Medical News.

ASCO says there is "no basis" to conclude that Medicare reimbursement levels for oncology services under the two main programs ― the Medicare Physician Fee Schedule (MPFS) for the office setting and the Hospital Outpatient Prospective Payment System (HOPPS) for the hospital outpatient setting ― should be substituted for one another because they are based on different data sets for rate setting.

The differences between MPFS and HOPPS are further exacerbated by separate conversion factors established by the Centers for Medicare and Medicaid Services (CMS) under rules that are unique to each care setting, according to ASCO.

"There is no reasonable rationale for concluding that reductions are warranted in the payment levels for either setting of care on the basis of payment levels established for the other setting," the policy says.

However, not everyone sees eye to eye with ASCO.

Kavita Patel, MD, managing director of clinical transformation at the Center for Health Policy, Brookings Institution, in Washington, DC, said she thinks site-neutral payments are "a smart way to go. It will save money." And the fact that it is in the bipartisan budget shows "support" for it, she said in an interview with Medscape Medical News.

"The people who are against site-neutral payments are largely hospital-based, and the people who are for it are largely not hospital-based. That's kind of how it divides. ASCO has members that are both hospital-based and non-hospital-based, and I think what they are basically trying to say is where you deliver these services shouldn't matter. It's what you deliver," Dr Patel added.

"Is there something that is so different about getting chemotherapy inside of a hospital vs outside of a hospital? I don't disagree that there are probably some elements [of care] that are better inside of a hospital, but I think now it's going to be up to the hospitals to prove it," Dr Patel said.

Current indicators are that ASCO is not going to have its way in this debate.

In a budget deal that is scheduled for a vote in the US House of Representatives today, it is anticipated that site neutrality will be approved as part of the deal, which means Medicare reimbursement rates will be equalized regardless of setting. The American College of Physicians and the American Academy of Family Physicians have supported the concept, as reported by Medscape Medical News.

Now Is the Time

ASCO's specific recommendations in their new statement include the following:

  • Creating value-based incentives rather than arbitrarily cutting payment levels on the basis of site of care

  • Ensuring that payment levels for physician practices provide adequate support for the full scope of medical and ancillary services required to treat individuals with cancer

  • Engaging in additional study of the full scope of services required by patients with cancer, including the specific needs of low-income individuals, before implementing any change in resources paid to oncology practices and hospitals

  • Transforming Medicare coding and payment for outpatient cancer care by implementing policies that are consistent with proposals such as ASCO's Patient- Centered Oncology Payment: Payment Reform to Support Higher Quality, More Affordable Cancer Care model.

Dr Stella placed the ASCO ideas in the context of ongoing healthcare reform.

"The Medicare physician reimbursement system is currently undergoing a complete transformation as the Medicare Access and Chip Reauthorization Act of 2015 (MACRA) is implemented, so now is the time to ensure that the needs of patients with cancer are appropriately addressed," he told Medscape Medical News.

"To that end, ASCO has established a special MACRA task force to develop a multiyear education and advocacy strategy. In the near term, ASCO is drafting comments in response to a request for information from the CMS on aspects of MACRA, including the Merit-based Incentive Payment System, promotion of alternative payment models (APMs) — which would appropriately address the issue of site neutrality — and incentive payments for participation in eligible APMs," he noted.

"MACRA becoming law, after an extensive advocacy campaign by the physician community, shows that physicians and policy makers alike recognize that the traditional, fee-for-service approach to Medicare reimbursement — on which site neutrality is based — has not worked, and all stakeholders are currently working out the specific details of implementing the law," Dr Stella added.

J Clin Oncol. Published online October 26, 2015. Full text

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