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Cancer Leadership Council comments on Medicare physician payment proposal for 2015
(September 2, 2014)

September 2, 2014

Marilyn Tavenner
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, DC  20201

Re:    CMS-1612-P, Revisions to Payment Policies Under the Physician Fee Schedule for CY 2015

Dear Ms. Tavenner:

The undersigned cancer patient and research organizations, who are members of the Cancer Leadership Council, are writing regarding the proposed rule updating physician payments for calendar year 2015.  Our organizations have significant and diverse experience related to the cancer care delivery system, and we offer advice about revisions to the physician payment system that would strengthen the delivery of care to cancer survivors after active treatment.

In comments regarding the last two proposed rules related to the physician fee schedule prior to the proposed rule at hand (published in 2012 and 2013), the Cancer Leadership Council applauded efforts by the Centers for Medicare & Medicaid Services (CMS) to strengthen care planning and coordination through the fee-for-service system.  We commented positively on the establishment of the transitional care management (TCM) code to pay separately for the care management related to the transition of the Medicare beneficiary from a hospital setting to a community setting, implemented in 2013, and the chronic care management (CCM) code that was defined in the proposed rule published in 2013 and that will be implemented in 2015.

These care planning and coordination codes hold some limited potential to support better coordinated care for cancer patients at certain points in their care trajectory.  We are pleased by some of the changes that CMS has made in the definition of the CCM code to be implemented in 2015, and we support the intent of CMS to achieve “effective care management” through “regular monitoring of the patient’s health status, needs, and services, and through frequent communication with the beneficiary and among health care practitioners treating the beneficiary.”  This statement expresses the fundamental principles underlying cancer survivorship care of high quality.  

The chronic care management service --  to be furnished to patients with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompression, or functional decline – might be provided to certain cancer survivors.  However, many more cancer survivors will not meet the defined standards to receive the CCM service, and as a result the CCM code/service will not provide assurance of planning and coordination of cancer survivorship care.

The Burden of Cancer Survivorship for the Medicare Program

The Institute of Medicine (IOM) report, “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis,” describes the demographics of cancer in the 21st Century.  According to the IOM, “The changing demographics in the United States will exacerbate the most pressing challenges to delivering high-quality cancer care.”  From 2010 to 2030, the United States population will increase by 19 percent, while the total cancer incidence will increase by 45 percent, from 1.6 to 2.3 million cases per year.  More than half of those cancer diagnoses will be among the elderly.

It is projected that there will be 18 million cancer survivors by the year 2022.  In 2012, almost three-fifths of cancer survivors were 65 and older.  If the age distribution of survivors remains relatively stable, the burden on Medicare for treatment and post-treatment survivorship care for beneficiaries will be significant.

CMS has taken important actions to address the challenges associated with the increased burden of cancer on the Medicare program, actions that we believe hold promise of improving the overall quality of cancer care for Medicare beneficiaries.  CMS has recently released for comment an Oncology Care Model that reforms Medicare payment for chemotherapy treatment, placing a heavy emphasis on transformation of oncology practice to foster patient-centered care.  Oncology practices that choose to participate in the Oncology Care Model will be required to undertake a cancer care planning process that will encourage shared decision-making and care coordination.  We applaud the focus on cancer care planning and coordination in the proposed Oncology Care Model.

We understand that the Oncology Care Model has not been officially released and that enrollment of other payers and oncology providers in the voluntary program is uncertain.  As a result, the future of the Oncology Care Model is not clear.  However, even if there is aggressive participation in the model and it positively influences cancer care quality, it may not address the challenges associated with delivery of and payment for survivorship care.

We urge CMS to bring to the task of cancer survivorship care the same openness and creativity it has brought to other reforms of fee-for-service payment to encourage care planning and coordination.

Options for Improving Cancer Survivorship Care

In a report that focused on enhancing cancer survivorship care, IOM determined that the post-treatment clinical and psychosocial care needs of cancer survivors are distinct from active treatment needs and represent a distinct phase of the cancer care trajectory.  In the report, “From Cancer Patient to Cancer Survivor: Lost in Transition,” IOM identified four critical components of survivorship care:

  • Prevention and detection of new cancers and recurrent cancer;
  • Surveillance for cancer spread, recurrence, or second cancers;
  • Interventions for consequences of cancer and its treatment (medical problems such as lymphedema and sexual dysfunction; symptoms, including pain and fatigue; and psychological distress of survivors and their families); and
  • Coordination between specialists and primary care providers to guarantee that the survivor’s health needs are addressed.

These components of care describe a complex system of care for survivors.  In addition, there are issues related to the best site for delivery of survivorship care and what roles specialists and primary care providers should assume.  

The quality of survivorship care could be positively influenced by access to a service, recognized through a specific fee-for-service code, for the planning and coordination of such care.  The Oncology Care Model that has been proposed by CMS for chemotherapy treatment assumes that cancer care providers will develop a care plan that identifies survivorship needs.  However, that plan will not assure quality survivorship care without the coordination of care among specialists and primary care providers, coordination that will also help to address issues related to site of care.  

We recommend that CMS begin discussions focused on the design and definition of a cancer survivorship coordination service.  Because cancer survivors have complex post-treatment health care needs that cannot be fully addressed through the TCM or CCM service, we recommend that they be provided access to a cancer survivor-specific care coordination service.  

Action to enhance cancer survivorship care will also provide benefits to the Medicare program through earlier detection of new and recurrent cancers and appropriate treatment of cancer and cancer treatment side effects, actions that might result in prevention of inpatient admissions and might also contribute to appropriate utilization of cancer care resources.  

We stand ready to provide resources and expertise related to survivorship care and strategies to improve it through modest, but important, Medicare fee-for-service reforms.


Cancer Leadership Council

Cancer Support Community
Fight Colorectal Cancer
International Myeloma Foundation
Kidney Cancer Association
The Leukemia & Lymphoma Society
Lymphoma Research Foundation
National Coalition for Cancer Survivorship
National Patient Advocate Foundation
Ovarian Cancer National Alliance
Prevent Cancer Foundation
Sarcoma Foundation of America
Susan G. Komen
Us TOO International Prostate Cancer Education and Support Network

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