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Study raises questions about PPS exemption for cancer centers

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Likely driver of decades-old legislation no longer applies today

Similarity of the hospitals affiliated with Prospective Payment System (PPS)–exempt cancer centers and the hospitals affiliated with National Cancer Institute–designated cancer centers hospitals likely results from the fact that most of the former group of centers also belong to the latter group of centers, even though the study considered these categories to be mutually exclusive, Robert Steinbrook, MD, proposed in an Editor’s Note.

“Surprisingly, the Centers for Medicare & Medicaid Services collects no comparative cancer-specific quality data for all the PPS-exempt and NCI cancer centers; the PPS-exempt cancer centers report some cancer-specific quality measures but the PPS itself uses no cancer-specific quality measures,” he pointed out.

Failure to uniformly collect and publicly report cancer-specific quality measures for all institutions “makes little sense,” Dr. Steinbrook contended, especially given that most PPS-exempt cancer centers are also NCI-designated cancer centers.

“In 1983, Congress may have believed that the care provided at certain cancer hospitals was not suited to reimbursement under the newly introduced DRG [diagnosis-related group] methodology,” he concluded. “In 2019, however, that belief no longer is tenable. [This study] is a call for greater transparency about the quality of cancer care in the United States, the establishment of one set of rules for how Medicare pays for cancer care, and an end to the PPS-exempt cancer center program.”

Dr. Steinbrook is editor at large and online editor at the JAMA Internal Medicine editorial office at the University of California, San Francisco, and is an adjunct professor at Yale University, New Haven, Conn.



It’s time to revisit legislation that exempts certain U.S. specialized cancer centers from the Medicare Prospective Payment System and from fully reporting measures of care and outcomes to the Centers for Medicare & Medicaid Services, a retrospective cohort study suggests.

The Prospective Payment System (PPS) exemption dates back to 1983 and allows exempted centers to be reimbursed on a reasonable cost basis rather than on a diagnosis-related group basis. Unlike centers that are a part of PPS, exempted centers are not required to report all process-of-care, outcome, and patient experience measures to CMS through its pay-for-performance programs.

In the new study, investigators working under senior author Karl Y. Bilimoria, MD, MS, director of the Surgical Outcomes and Quality Improvement Center and John B. Murphy Professor of Surgery at Northwestern University, Chicago, compared a variety of measures across hospital types. Data came from the American Hospital Association Annual Survey, U.S. News Best Hospitals rankings, and a sample of Medicare beneficiaries who underwent nine cancer operations.

Analyses were based on 15 hospitals affiliated with PPS-exempt cancer centers, 54 hospitals affiliated with National Cancer Institute–designated cancer centers, and 3,578 other U.S. hospitals providing cancer care. The results reported in JAMA Internal Medicine showed that hospitals affiliated with PPS-exempt cancer centers and hospitals affiliated with NCI cancer centers were similar on characteristics other than bed size and overall volume, which were larger for the latter, and on basic cancer-related services such as full-field digital mammography, genetic testing/counseling, chemotherapy, image-guided radiation, and hospice/palliative services.

U.S. News reputation scores averaged 17.5 for the PPS-exempt cancer center hospitals versus just 2.6 for the NCI cancer center hospitals (P less than .001). However, the two types of centers were statistically indistinguishable on oncology patient volume, patient safety ratings, comorbidity burden, nurse staffing, and U.S. News survival scores.

When it came to cancer operations, hospitals affiliated with PPS-exempt cancer centers and with NCI cancer centers had essentially the same adjusted postoperative outcomes for 15 of 18 measures, including mortality, readmission, and surgical site infections. Patients treated at the latter more often developed postoperative sepsis (3.1% vs. 1.7%; P = .002), acute renal failure (6.2% vs. 3.9%; P = .01), and urinary tract infection (6.4% vs. 4.0%; P = .002).

PPS-exempt cancer center hospitals had better outcomes than the group of other U.S. hospitals providing cancer care for 7 of the 18 oncology surgery measures, including mortality, sepsis, acute renal failure, pulmonary failure, and failure to rescue.

“Although PPS-exempt cancer centers may serve an important purpose by advancing the science and quality of cancer care, limited information is available on the selection of PPS-exempt cancer centers, their reimbursement, and how these centers compare with other hospitals with regard to quality of care,” Dr. Bilimoria and colleagues wrote.

“Our findings suggest the need for additional transparency, periodic reviews of the program by CMS, and consideration of whether the classification of PPS exemption should continue. Moreover, the requirement to publicly report cancer care–quality metrics should be uniformly applied across all types of hospitals, not just PPS-exempt cancer centers,” they concluded.

Dr. Bilimoria reported receiving support from the National Institutes of Health; Agency for Healthcare Research and Quality; American Board of Surgery; American College of Surgeons; and the Accreditation Council for Graduate Medical Education, Health Care. The study was supported by the Northwestern Institute for Comparative Effectiveness Research in Oncology of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.

SOURCE: Bilimoria KY et al. JAMA Intern Med. 2019 June 17. doi: 10.1001/jamainternmed.2019.0914.

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