Dr. Bailes Looks at CMS Quality of Care Reporting Project and Healthcare-Related Legislation for 2007

May 1, 2007

Since the Medicare Modernization Act (MMA) of 2003 was signed, the Centers for Medicare & Medicaid (CMS) has initiated a series of fairly dramatic structural changes in reimbursement policies covering drugs and services provided in cancer care.

ABSTRACT: Since the Medicare Modernization Act (MMA) of 2003 was signed, the Centers for Medicare & Medicaid (CMS) has initiated a series of fairly dramatic structural changes in reimbursement policies covering drugs and services provided in cancer care. Cancer Care & Economics (CC&E) recently spoke with Joseph S. Bailes, MD, co-chair of the American Society of Clinical Oncology's (ASCO) Government Relations Council. Dr. Bailes elucidated some of the upcoming issues facing cancer specialists in today's changing political environment.

CC&E: The Oncology Demonstration Projects of '05 and '06 were well received by the oncology community. Does CMS plan to initiate a similar volunteer program in the future?

DR. BAILES: Although ASCO urged Congress and the Administration to continue the program, CMS did not commit to a 2007 demonstration project. However, during the lame duck session, Congress passed a conversion factor update that amounts to an increase of 1.5% in physician payments for reporting quality measures through the CMS Physician Voluntary Reporting Program (PVRP), which is now known as the 2007 Physician Quality Reporting Initiative (PQRI). ASCO will be working with CMS to ensure a smooth transition to the new program. [See article on page 50 for more on this new program.]

CC&E: How does ASCO view the merit of the PQRI?

DR. BAILES: We're hopeful that it will have a positive effect on cancer care practices. In theory, just like the demonstration projects, under PQRI physicians can elect to participate; however, if you don't elect to participate, you don't get the 1.5% bonus payment. CMS is using these initiatives to establish a broader system that rewards healthcare providers for recommended care. In other words, PQRI could be a preliminary step in the move toward P4P [pay for performance]. Clearly our docs are ahead of the curve in that they've had 2 years of experience reporting quality measures that resulted in payment, so this is not going to be new to them.

CC&E: Has ASCO's work on the Hill raised awareness about the problem of underwater drugs?

DR. BAILES: It's a challenge, but I think we are gaining ground. This year, ASCO worked with leaders in Congress to advance a bill introduced by Rep. Ralph Hall (R-Tex) to correct this, but unfortunately we couldn't get it added in the lame duck session. We've been meeting with the new leadership, and we will certainly reintroduce that bill. Hopefully we'll convey to the newly elected Democrats the importance of fixing this problem.

CC&E: Are the proposed reimbursement cuts in imaging services a concern with ASCO?

DR. BAILES: It's definitely a concern with ASCO. A study released by the Access to Medical Imaging Coalition (AMIC) showed that total reimbursement for imaging services in physician offices will fall nearly 19% below that of the reimbursement totals for similar services provided in hospitals or other health care settings. But the cuts have garnered bipartisan concern among those in Congress who understand that PET, CT, and MRI are essential components of quality oncology care.

To that end, in February, Reps. Carolyn McCarthy (D-NY), Gene Green (D-Tex), and Joseph Pitts (R-Penn) introduced legislation to delay additional cuts for Medicare imaging over the next 2 years. The Access to Medicare Imaging Act of 2007 [H.R. 1293] would require CMS to halt additional cuts that went into effect at the beginning of this year. The bill also calls for the Government Accountability Office (GAO) to evaluate the impact of the cuts on patient access to care and quality services.

CC&E: Would you comment on the administration's line-item budget cut to the Institutes of Health (NIH).

DR. BAILES: This is another serious issue with ASCO. Congress increased the NIH budget by 2% for FY2007, but the President's proposed FY2008 budget calls for decreases in both NIH and NCI funding. Given the potential upcoming budget cuts, the research infrastructure, a critical component of cancer treatment, is in jeopardy. In the next year, ASCO will work with Congress to increase funding for NIH by at least 6.7% for the next 3 years, building on the provisions outlined in the National Institutes of Health Reform Act [H.R. 6164].

CC&E: Is there any other legislation that we should keep our eyes on?

DR. BAILES: Reps. Lois Capps (D-Calif) and Tom Davis (R-Va) reintroduced the Comprehensive Cancer Care Improvement Act of 2007 [H.R. 1078]. The bill would establish a new Medicare service for comprehensive cancer planning throughout the continuum of cancer care—from diagnosis to treatment to survivorship. H.R. 1078 also includes provisions for the improvement of symptom management and palliative care in cancer patients.

CC&E: What's your take on the new Congress as it relates to the oncology community?

DR. BAILES: Obviously, the new Democratic majority will try to shift the focus of the Congressional agenda. For example, the Democrats have introduced bills to give Medicare the authority to negotiate with drug companies for lower drug prices. Another of their priorities includes fixing the coverage gap called the "doughnut hole," which begins when drug expenses total $2,250 and continues until the beneficiary has spent $3,600.

We may also see some legislation looking at the sustainable growth rate (SGR) and how it relates to setting appropriate fees for physicians' services.

Otherwise, it's very difficult to prognosticate what new directions Congress will take. But it's important to remember, although the House has a fairly significant majority, about 30 votes, the Senate's Democratic majority is only one vote. So while the message coming from some people on the Hill may seem negative, the ability to get radical healthcare legislation passed is going to be a challenge. I think that's one way to reassure folks in the oncology community who are concerned about certain political changes that might adversely affect their practices.

CC&E: Any closing thoughts?

DR. BAILES: One thing we're going to have to do with the new Democratic leadership, and it's important for your readers to know, is get congressional members and their staff out to oncology offices and treatment centers so they can see first-hand the complexity of delivering cancer care. This way, when we're on the Hill advocating for adequate payment for services, they will have a clear picture of what the "full spectrum of services" actually is. We need to make the effort to educate these new policy-makers and increase their recognition of what oncologists are up against. As always, ASCO encourages its members to contact their senators and representative about these important issues.