Here we explore the latest evolution in Medicare coverage policy and coverage with evidence development (CED), discussing how it developed and what it means for practicing oncologists. Coverage with evidence development is a tool used by the Centers for Medicare & Medicaid Services (CMS) in an attempt to bring a new rationale to payment decisions and, ultimately, cost savings to the Medicare program

ASCO’s Quality Oncology Practice Initiative (QOPI), launched in 2002, is an oncology-specific quality-improvement program for which measures are developed and revised by practicing oncologists and measurement experts. MS has its own quality program, the Physician Quality Reporting Initiative (PQRI), which emphasizes “value-based purchasing,” quality of care, and successful physician reporting. PQRI is based on 74 quality measures and rewards reporting with bonus payments of 1.5% of allowed Medicare charges for the reporting period—July 1, 2007, through December 31, 2007. A minimum 80% reporting rate is required to be eligible for bonuses. CMS has proposed extending the PQRI into 2008.

Whether this will negate the validity of the decision or the evidence remains to be seen, but it is one potential challenge that CED will have to face as it finds its form. Another challenge is that the shift to simultaneous consumption and generation of evidence will mean more work for clinicians and patients alike, but effective methodologies and technologic infrastructure should ease the transition.