2006 CMS Oncology Demonstration Project Aims to Improve Quality Through Evidence-Based Care

HOLLYWOOD, Florida—After a rocky start with a 2005 Demonstration Project designed to assess symptoms of nausea and vomiting, pain, and fatigue in Medicare patients receiving chemotherapy, the Centers for Medicare & Medicaid Services (CMS) has shifted toward improving quality through more effective payments and evidence-based care. This will include assessing whether patients are treated according to evidence-based standards of care (typically the NCCN or ASCO guidelines) and focusing payments on patient-centered care rather than administration of chemotherapy, Christopher E. Desch, MD, national medical director of the National Comprehensive Cancer Network, said at the 11th Annual NCCN Conference.

"By focusing on evidence-based practice, there is the potential that unnecessary services and tests will be reduced, lowering program costs and yielding better quality of life for Medicare beneficiaries with cancer," Dr. Desch said.

Office-based medical oncologists and hematologists are eligible for participation in the Demonstration Program, which is voluntary and occurs on a claim-by-claim basis. CMS will make an additional payment of $23 when appropriate G-codes from specified categories are submitted by physicians to Medicare. The total project is expected to cost $150 million. The 13 included diagnoses are breast, colon, esophageal, gastric, head and neck, non-small-cell or small-cell lung, ovarian, pancreatic, prostate, and rectal cancer; chronic myelogenous leukemia; multiple myeloma; and non-Hodgkin's lymphoma.

Dr. Desch said that physicians participating in the Project are asked to report three things: the primary focus of the patient visit (eg, supervision of therapy and toxicity management, palliation and pain control, or surveillance for disease recurrence); the status of the patient's cancer by cell type and stage of disease; and whether management adheres to NCCN or ASCO guidelines.

The NCCN has produced a useful tool that maps the NCCN guidelines for each of the 13 cancers in the CMS project to the new G-codes assigned to the three relevant management areas. These were distributed on a CD-ROM to office-based medical oncologists and hematologists in the United States and are also available at www.nccn.org.

The maps provide a straightforward path: clicking on the disease state code opens a link to the visit type, which is linked to the applicable NCCN guidelines recommendations, to NCCN supplemental information, to CMS guidelines adherence coding, and to the codes for reimbursement.

"We will have more here than just a new billing mechanism," Dr. Desch said. "We will have more detailed information on this treatment population than has ever been collected before, and this project will show whether this data collection mechanism will work."

CMS's concern is partly driven by the variation in Medicare spending per beneficiary, which ranges from $3,341 in Minneapolis to $8,881 in Miami, a difference in lifetime cost of about $50,000, Dr. Desch said. Only 27% of that difference is attributable to differences in demographics, price, and health status. "Do you get more effective care in high-spending than in low-spending areas? The answer is no," Dr. Desch said.

Project Goals

A major goal of the project is to increase the use of underused effective care, such as radiotherapy in stage II or III rectal cancer (utilization of which varied from 52% to 92% in five metropolitan regions). Another goal is to decrease the use of ineffective care, such as chemotherapy given less than 14 days before a cancer patient's death.

The final result is expected to be a national data set that will permit analysis of outcomes relative to many aspects of the patient's treatment. "It's a structure for pay-for-performance," Dr. Desch said. "The 2006 demo pays doctors for collecting data, promotes awareness and adherence to guidelines, and potentially creates a new tool for national quality improvement."