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Donald Berwick, M.D.
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1345-P
Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, Maryland 21244-1850

RE: CMS-1524-P
RIN 0938-AQ25
Proposed Rule on Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2012

Dear Dr. Berwick:

The National Coalition for Cancer Survivorship (NCCS) is pleased to submit comments on the proposed rule on the Medicare program; payment policies under the physician fee schedule and other revisions to Medicare Part B for CY 2012. NCCS, a national organization representing survivors of all forms of cancer, commends the Centers for Medicare & Medicaid Services (CMS) for highlighting the issue of care coordination and care transitions when a Medicare beneficiary is discharged from a hospital.

In 2011, more than 1.5 million Americans will be diagnosed with cancer, and it is estimated that more than half of all new cancer diagnoses occur among the elderly who are enrolled in Medicare. In addition, more than 12 million Americans are living with cancer, including a significant number who are Medicare beneficiaries. The National Cancer Policy Forum of the Institute of Medicine (IOM), in the report, “From Cancer Patient to Cancer Survivor: Lost in Transition,” detailed the significant effects that cancer and its treatment have on the “…health, function, sense of security, and well-being” of cancer survivors. The needs of cancer survivors are significant, and the resulting burden on the Medicare program is great. Better interventions to address the needs of survivors would help individual beneficiaries and the Medicare program.

The proposed rule addresses many important issues, but we focus our comments on Section K of the proposed rule “Hospital Discharge Care Coordination,” which solicits comments on how to further improve physician care coordination within the statutory structure for physician payment and quality reporting, particularly for a beneficiary’s transition from the hospital to the community.

We provide input on two areas of particular importance to cancer survivors: namely, care coordination around a hospital discharge and the provision of a treatment care plan upon hospital discharge. Care coordination after a patient is discharged from the hospital is of growing significance as an increasing amount of care is performed outside of the hospital, including, but not limited to, complicated medication and chemotherapy regimens in the case of cancer survivors. The IOM Lost in Transition report identified care coordination as one of four components of survivorship cancer care. It specifically highlighted: “coordination between specialists and primary care providers to ensure
that all of the survivor’s health needs are met (e.g. health promotion, immunizations, screening for both cancer and noncancerous conditions, and the care of concurrent conditions). Essential to survivorship care is a patient-centered approach, including responsiveness to patients’ needs, effective communication and information sharing...” We highlight a number of areas where the proposed rule could further IOM’s recommendations in this area.

The proposed rule lists a number of care coordination activities for both the treating physician in the hospital, as well as the beneficiary’s primary care physician in the community overseeing the patient’s care post-hospital discharge. These include, but are not limited to, the transfer of “core” information to the receiving physician and beneficiary/family (if requested), such as important lab results, prescribed drugs, physician coverage for problems that arise prior to any initial appointment, among others. We support the inclusion of all of the listed activities as key physician activities that form important parts of the transition of the patient from the hospital to the community.

The proposed rule also asks for comment on the clinical vignettes for the hospital discharge and office visit codes, particularly the extent to which they appropriately reflect the resources involved in performing activities essential to the coordination of care surrounding a hospital discharge. Under “Intra Service,” we would also like to suggest adding a discussion of the goals of treatment postdischarge (as applicable) and time taken for a psychosocial assessment of the patient (or referral for such an assessment). Also, under “Post-service,” the vignettes indicate that the treatment plan(s) is revised and communicated with the patient. It is also important to clarify that a care plan be documented and delivered to the patient, as well as caregivers (if desired) and relevant physicians and health care providers. This is important as it will enable the patient to retain the plan for reference and can help further treatment, and promote the appropriate use of medical resources by highlighting, for example, the side effects to be expected, what action is to be taken with respect to which side effects, when a sign is an emergency, and other important pieces of information that a patient needs to be mindful of after discharge.

Importantly, the proposed rulemaking requests comment on the use of shared care plans between the beneficiary and the physician rather than those created solely by the physician. Such plans are jointly developed by the beneficiary and the physician where the physician sets and documents selfmanagement goals collaboratively with beneficiaries. NCCS strongly advocates the increased use of cancer survivorship care treatment plans developed in consultation with the patient and provided in writing to the patients and other providers caring for the patient. Similarly, care treatment plans are important for patients with chronic and/or complex diseases, and patients being discharged from the hospital. Physician consultation with the patient, and consideration of patient preferences in the development of the treatment plan, is necessary to ensure that the treatment plan reflects the patient’s goals. Reimbursement should be sufficient to support a lengthy and robust discussion between the physician and patient, including cancer patients, who may be in the middle of treatment for lifethreatening illness, or beginning the phase of post-treatment care where important follow-up and symptom management will be necessary.

In addition, the proposed regulation should incorporate initial and ongoing communication between the providers caring for the discharged patient, particularly the discharging physician and the primary care or other physician charged with overseeing the patient’s care after the hospital stay. While it arguably could be included within such “Intra Service” as “Discuss aftercare treatment with the patient, family and other health care professionals” and the “Post Service” of “provide necessary care coordination…,” within “Table 63: AMA RUC Clinical Vignette,” it may be useful to explicitly include this.

Finally, it will be important to measure the quality and effectiveness of the plan of care provided to patients discharged from the hospital, as well as the quality of the care received. In addition, the effectiveness of communications with the patients, particularly around areas where they are expected to implement or manage their care, such as drug adherence, should be evaluated and lessons communicated to providers so that they may improve the quality of the care provided.

We appreciate the opportunity to offer comments on this proposed rule and look forward to working with the agency to ensure that this rule improves the quality of care provided to cancer survivors. Please do not hesitate to contact us if you have questions or need clarifications on any of our comments.