The Medicare Shared Savings Program (MSSP) will likely be a nonevent for oncology. Initially, many expected that the accountable care organization (ACO) framework implemented through the 2010 Patient Protection and Affordable Care Act’s MSSP would speed up changes that were already in progress, such as intensifying shifts toward hospital employment of oncologists, creating integrated delivery systems in geographic areas, and requiring oncologists either to form their own ACOs or figure out how to plug into established ACOs. Those expectations were quashed, however, after the Centers for Medicare & Medicaid Services (CMS) released its proposed rule for the MSSP (see sidebar), and would-be participants realized how burdensome and proscriptive it would be to implement the program. More important for oncology, under the proposed rule, it seems that the CMS does not intend for the shared savings program to tackle cost-effectiveness in the oncology setting for the following reasons:
- Oncologist-managed patients are not considered in the MSSP and would not be assigned to an ACO (see sidebar);
- Even if oncologist-managed patients were to be included in the MSSP, they would still likely be excluded by the outlier threshold because their treatment and management costs are so high;
- Even if the rules were to be changed to count oncologist-managed patients who exceed the proposed outlier threshold, the CMS approach of inflating historic spending to set future targets would not allow for a dynamic standard of care in oncology, with the new, costly therapies that are likely to emerge over any 3-year window.
The upshot is that the MSSP provides no incentive for oncologist participation in ACOs, and oncologist participation under a system that bases future targets on historic spending would likely result in missed targets and shared loss payments back to the CMS. With the expected rapid growth of the cancer patient population and the high relative costs to Medicare, it is likely that the CMS will consider targeted approaches to value-based reimbursement in oncology outside of the MSSP. Community oncology practices would be better served by preparing for a targeted oncology approach with private payers and the CMS rather than through the one-size-fits-few MSSP....
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