Donald Berwick, M.D.
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, Maryland 21244-1850
Proposed Rule on Medicare Shared Savings Program: Accountable Care Organizations
Dear Dr. Berwick:
The National Coalition for Cancer Survivorship (NCCS) is pleased to submit comments on the proposed rule for Accountable Care Organizations (ACOs) to be implemented under the Shared Savings Program provisions of the Affordable Care Act. NCCS, a national organization representing survivors of all forms of cancer, commends the Centers for Medicare & Medicaid Services (CMS) for proposing a system of ACOs aimed at better care for individuals, better health for populations, and lower growth in expenditures. The proposed rule envisions a system of care that would encourage collaboration among providers, care planning and coordination, and evidencebased decision-making.
Our comments focus on: 1) the critical emphasis on patient-centered care, which will encourage individualized care planning and care coordination important for enhancing the quality of cancer care and survivorship services, 2) the need to protect cancer patients’ access to specialty care and care in clinical trials, and 3) ACOs as a step toward the creation of “medical communities” including primary care networks linked with specialist referral networks. The medical community approach may be important in meeting the acute care needs of cancer patients by providing them access to high-quality, evidence-based treatment and fostering their transition to long-term survivorship care including monitoring, diagnosis, and treatment of late and long-term effects of cancer and cancer treatment.
Principles of Patient-Centeredness
We are pleased that CMS has identified a set of eight strong principles of patient-centeredness including: 1) development of individualized care plans based on the patient’s needs, preferences, values, and priorities, 2) involvement of patients and families in evidence-based decision-making about care choices, 3) development of processes to ease transitions of care among providers, 4) routine surveying of patients regarding their satisfaction with their care, 5) identification of population health needs and consideration of diversity, and 6) involvement of patients in ACO governance. Articulating the principles of patient-centered care is important for establishing fundamental standards for the operation of ACOs. However, to realize the promise of patientcentered care, it is critical that ACOs develop systems of care that are aligned with the principles of patient-centeredness. Important initial steps will be: 1) encouraging a process for open communication between patients and health care providers and 2) establishing processes for development of comprehensive and patient-centered care plans.
NCCS supports the recommendation to include a Medicare beneficiary on the ACO governing body. We agree that safeguards should be implemented to protect against conflicts of interest and that the beneficiary member of the governing board should not be a provider or supplier in the ACO network. A beneficiary advisory committee or panel should be established, in addition to – but not as a replacement for – inclusion of a beneficiary or beneficiaries on the governing board. An advisory panel would be useful in providing to the ACO leadership and ACO providers information and counsel about the health care needs of specific groups of patients. For example, cancer survivors would be invaluable as members of an advisory panel for their ability to provide guidance about the acute and chronic health care needs of survivors and strategies for improving care through coordination and planning. We believe that other members of a beneficiary advisory panel would be able to provide comparable advice about the special health care needs of other groups or populations of beneficiaries.
Implementation of Individualized Care Plans
NCCS endorses the recommendation that ACOs identify high-risk individuals and develop individualized care plans for target patient populations. We strongly support the availability of individualized care plans for cancer patients. We have long recommended that cancer patients be provided, in the period immediately following their diagnosis, a care plan that includes the goals of care as well as all elements of active treatment and supportive care. This plan should be amended if there are changes in the patient’s condition or treatment. The plan should also be modified and expanded at the end of active treatment and transition to survivorship to include a summary of treatment to date and a plan for monitoring and care of late and long-term effects during survivorship. For cancer patients, the care plan is critical to patient involvement in treatment decision-making, access to quality care, and a smooth transition to survivorship.
Cancer care planning is also critical for provider self-assessment and quality improvement. Evaluation of providers’ completion of the care planning process and the impact of care planning on utilization of resources and patient involvement in care can support quality cancer care improvement activities. We note that the proposed rule provides that the plan would be voluntary and privacy protected. As advocates for cancer survivors, we understand the need to protect privacy. However, to ensure that cancer care plans and the process of developing them also serve as quality improvement efforts, we recommend that beneficiaries be asked to authorize the use of their plans for quality improvement purposes.
We are pleased that CMS proposes that the individualized plan identify community and other resources to support the beneficiary as he or she receives care according to the plan. Knowledge of and access to such community resources are of critical importance to cancer survivors, who may rely on psychosocial and other services during their active treatment as well during the period of cancer survivorship.
Primary Care Providers
NCCS understands that ACOs are provided flexibility in determining the number and types of providers that will be necessary to participate in the program and meet the needs of the beneficiaries assigned to them for a performance year. We urge consideration of specialists providing significant primary care services for inclusion on the ACO team. The burden of cancer is great among Medicare beneficiaries, as approximately 60 percent of cancer diagnoses occur among the elderly. As a result, ACOs may find themselves facing substantial responsibility for coordinating cancer care. For some cancer survivors, a cancer care specialist may provide primary care services and may function as the coordinator of cancer care. Such specialists should be considered for participation on ACO primary care teams.
We support the requirement that ACOs meet quality performance standards in addition to reducing costs in order to receive a shared-savings payment. We also understand the difficulty of developing a set of measures that is adequate to measure performance and at the same time does not impose an unreasonable burden on ACOs. The 65 measures that have been identified for performance year 1 are already subject to criticism for being too burdensome. The concern of NCCS relates not to the total number of measures but instead to the flexibility for incorporating measures that may be most appropriate for cancer care. For example, care coordination measures that refer specifically to cancer care planning processes and documents may be more useful for assessing the care of cancer survivors than the measures in the current set of 65. In addition, long-term survivorship care measures may be more useful for assessing the quality of care provided to survivors than the preventative health measures in the set of 65 in the proposed rule.
CMS has chosen to permit ACOs flexibility in determining the guidelines they will utilize to support evidence-based decision-making. The proposed rule would require ACOs to describe the evidencebased guidelines they will establish, implement, and periodically update. While NCCS does not object to this flexible approach, we recommend that there be a clearly articulated standard for updating evidence-based guidelines. The standards for cancer treatment, cancer care planning and coordination, cancer screening and early diagnosis, and survivorship care are constantly evolving based on new evidence, and ACOs should be required to update their guidelines consistent with new evidence and standards of care.
Retrospective Assignment of Patients
We have considered the arguments CMS has identified in favor of prospective assignment of patients to ACOs as well as those supporting retrospective assignment. We agree with the agency that the decision is a difficult one. Retrospective assignment of patients, combined with monitoring of the performance of ACOs with regard to avoidance of at-risk patients, may offer protections to cancer and other patients or individuals who would be considered “at-risk.” We therefore support the agency’s decision to assign beneficiaries in this manner. We fear that prospective assignment might carry some risk that providers would “cherry pick” and seek to avoid certain high-risk individuals, including, but not limited to, those receiving care for, or with a history of, cancer. It will nonetheless be important to encourage patient engagement and commitment by actively informing beneficiaries that their providers are functioning as an ACO and that they MAY be assigned to the ACO.
Access to Specialists and Care in Clinical Trials
Although the majority of cancer patients receive high quality care in community oncology and hematology practices, many still receive care in National Cancer Institute-designated cancer centers or other academic health centers. Referral to cancer or academic centers may be especially important for those diagnosed with rare cancers, those with complex health care needs or complex cancer diagnoses, and those seeking enrollment in clinical trials testing investigational agents. These specialized centers for cancer care are likely to receive indirect medical education (IME) payments, disproportionate share hospital (DSH) adjustments, and geographic adjustments. Because these amounts are not proposed to be removed from the benchmark and calculation of expenditures for an ACO, the institutions receiving them will be viewed as expensive sites for care. As a result, ACOs will have an incentive to decline referrals to these institutions.
The result of these decisions by CMS regarding the calculation of the benchmark may be serious obstacles to care that may be the best, if the not only, option for certain cancer patients. We urge the agency to change the calculation of the benchmark and expenditures for ACOs to exclude geographic adjustments, IME payments, and DSH adjustments.
Next Steps to Realize the Promise of Coordinated Care for Cancer Survivors
We applaud the efforts of CMS to implement the Shared Savings Program through ACOs. Despite our reservations about some potential adverse effects of ACOs for cancer patients, we commend the agency for articulating strong standards for patient-centered care and requiring processes and procedures that will ensure these standards are reflected in the care provided by ACOs. The emphasis on care planning, care coordination, and evidence-based decision-making represents an important evolution in the Medicare program and a groundbreaking change in the way providers will care for Medicare beneficiaries.
The principles of patient-centered care might best be put into action for cancer patients in a system that would link primary care providers and networks of cancer care specialists. Such a system would permit the coordination of care that is necessary to ensure quality and efficiency in interdisciplinary cancer care, ease the transition from active treatment to survivorship, and detect and treat second or recurrent cancers and other side effects of cancer and cancer treatment. A “medical community” for cancer care would also facilitate the active engagement of patients and families across the continuum of care from diagnosis through treatment to survivorship.
We appreciate the opportunity to offer comments on the design and implementation of ACOs and look forward to working with the agency to ensure that this model improves the quality of care for cancer survivors.
In addition, NCCS also signed on to support the efforts of others whose vision for ACOs are shared by NCCS: