Denver (3-30-17)—The oncology landscape is rapidly evolving. A Pharmaceutical Research and Manufacturers of America report noted that 836 oncology drugs and vaccines are in the pipeline, 123 of which are for lung cancer, and 80% of pipeline agents are potential first-in-class therapies. Because of this, existing treatment paradigms are regularly upset. In addition, oncology costs continue to grow, with a reported $105 billion spent globally in 2015 and projected to rise 7.5% to 11.5% annually through 2020. In response, payers are using clinical pathways, preferred product and exclusion lists, and value assessment framework tools for better management of costs and care. Value-based risk sharing models among payers, providers and pharmaceutical manufacturers are also evolving.

During a presentation at the AMCP Annual Meeting, Maureen Hennessey, PhD, CPCC, senior vice president and director of quality and population health solutions, and Jeremy Schafer, PharmD, MBA, senior vice president and director of specialty solutions, both of Precision for Value, discussed how payer management of oncology continues to evolve and what to expect in the future.

Drs. Hennessey and Schafer discussed programs impacting the oncology landscape, as the Centers for Medicare & Medicaid Services continues shifting to value-based reimbursement models to incentivize innovation for smarter spending and better care.

The Medicare Advantage Five Star program rates and compares Medicare Advantage plans based on a 5-star scale, rewarding 4 and 5-star performance.  Using Precision for Value’s QnavTM tool, the speakers gave two examples of national performance on cancer screening measures. In one example, the national percentage of 52 to 74-year-old female plan members who had a mammogram in the previous 2 years was 73%, which garnered a National Star Average of 4.0.  In another example, the national percentage of 50 to 75-year-old members who received appropriate colon cancer screening was 68%, which earned a National Star Average of 3.2.  It was noted that opportunities remain to close screening gaps through best practices such as identification and outreach to members who have not yet been screened.  The audience was referred to the National Colorectal Cancer Roundtable website to learn more about ways to achieve its “80% by 2018” screening goal.

The Medicare Access and CHIP Reauthorization Act of 2015’s Quality Payment Program (QPP) ends the use of the sustainable growth rate formula for Medicare Part B and replaces it with a choice of two reimbursement tracks:

  1. The Merit-Based Incentive Payment System
  • Payment in 2019 will be based on 2017 performance on quality measures (60%), improvement activities (15%), advancing care information (25%), and cost (0% currently, but is expected to increase in 2018)


  1. Advanced Alternative Payment Models
  • Incentive payments will support high-quality and cost-efficient care among risk-bearing programs such as the two-sided Oncology Care Model

This is the QPP’s transitional year, and requirements will expand in upcoming years, with incentives and penalties growing as well.  Practice improvement activities like periodic, structured medication reviews and medication reconciliation may potentially support oncologists’ performance on quality measures such as medication documentation, tobacco use intervention, appropriate use of chemotherapy, and pain management.

The Oncology Care Model (OCM) is an episode-based payment model aiming to align financial incentives for improved care coordination, appropriateness, and access for chemotherapy patients. OCM participation requirements include 24/7 clinician access, continuous quality improvement, patient navigation, documented care plans addressing issues such as medication toxicities, and nationally recognized clinical guideline use. Beginning in July 2016, the five-year OCM pilot encompasses approximately 155,000 Medicare beneficiaries, more than 3,200 oncologists and 16 payers.

OCMs receive six-month episode-based payments which include Medicare fee-for-service payments, as well as:

  • $160 per beneficiary per month for enhanced services (e.g., care coordination)
  • Performance-based payment based on risk-adjusted cost targets and quality measure performance scores

Cost targets integrate an adjustment for novel therapies, but OCM data should be monitored for care variations and changes in novel therapy adoption rates.

OCM quality measures address hospital and emergency department (ED) use, pain management, and timely access to appropriate chemotherapies.  Suggested innovations and solutions for better quality measure performance included:

  • Oral chemotherapy medication and symptom management programs for patients and caregivers to minimize avoidable hospitalizations and ED visits
  • Information campaigns for patients and caregivers about opioid safety and appropriate use to reduce pain and prevent misuse
  • Patient navigation programs offering integrated care and medication management to sustain patient motivation and timely access to therapies


The presentation by Drs. Hennessey and Schafer was also summarized and included in a special article drafted by the AMCP, highlighting the 5 key takeaways from this year’s Annual Meeting. To read the complete summary, please click here.