Community Oncology Alliance HOPPS Comments Support Additional 340B and Site Neutral Changes, Warns of Problems With Middlemen in CAP Proposal

September 25, 2018

Administration Must Focus on Strengthening the Part B Program, Tread Carefully With Changes That Might Have Unintended Consequences for Patients

The Community Oncology Alliance (COA) submitted formal comments to the Centers for Medicare & Medicaid Services (CMS) in support of proposed additional changes to the 340B Drug Discount Program and site-neutral payments that were put forth in the Hospital Outpatient Prospective Payment (HOPPS) rule for 2019. COA also cautioned CMS against proposals to introduce new third-party middlemen to the Part B system given the negative impact it will have on patient care.

COA applauds CMS for taking decisive steps in the 2019 HOPPS rule to address tremendous Medicare Part B spending increases that have resulted from the growing shift of care from independent community practices to hospital outpatient departments (HOPDs). Higher costs and utilization of drugs and services in HOPDs, combined with ever-expanding use of HOPDs due to provider consolidation, are driving up spending in Part B. Numerous independent studies over the years have shown this to be true, including a recent analysis showing that the mean per member per month cost of oncology care was 20% to 39% lower for those receiving chemotherapy in an independent community oncology practice compared with the hospital outpatient setting.

With the 2019 HOPPS proposal, CMS continues its leadership in recognizing this troubling pattern and advancing several important provisions dealing with extending site-neutral payment changes and the 340B Drug Pricing Program. These are intended to level the playing field between hospitals and independent community practices. Most importantly, they will have the effect of reducing costs to seniors, Medicare, and taxpayers. As a result, COA fully supports CMS’ 2019 HOPPS proposals around 340B and site-neutral payments.


In the comment letter, COA cautions CMS against any proposals to introduce new third-party middlemen to the Part B system through a renewed Competitive Acquisition Program (CAP) or similar styled model. These middlemen will threaten to interfere with the quality, accuracy, and timeliness cancer treatment for seniors, our most vulnerable patients. This would be particularly true for patients with cancer who would suffer under formulary restrictions or utilization management because there are few therapeutic and generic-to-brand substitutes in oncology.

The experience of community oncology practices and patients with middlemen, such as pharmacy benefit managers (PBMs) in Medicare Part D and commercial pharmacy benefit plans, is nothing but an increasing nightmare for patients and their providers. Getting patients their cancer drugs in a timely manner is bad enough, but providers also have to routinely deal with middlemen switching drugs and providing incorrect dosages. CMS opening up the door to middlemen in Part B would seriously jeopardize cancer patients’ access to appropriate and timely cancer treatment, while failing to generate any meaningful Medicare savings.

Finally, COA notes that any proposed reforms to Part B be carefully considered in the broader context of a shift to value-based care in Medicare and beyond. Community oncology practices, COA, and CMS have invested heavily in the success of the Oncology Care Model (OCM), an alternative payment model we believe can be a great success for both patients and providers. CMS must consider the impact its proposals to change the Part B program would have on patients and other ongoing value-based models. Burdensome changes to the current, very efficient, in-office drug delivery system could disrupt the delicate balance of the interaction between current value-based programs and would result in negative consequences for both providers and the patients they serve.

Overall, the letter notes that COA strongly supports CMS’ efforts to improve our cancer care system and reform bad public policies that have empowered hospital consolidation. However, policymakers must focus on strengthening the Part B program and tread carefully with changes that might have unintended consequences for patients with cancer.

Read COA’s full comment letter here at