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The care provided at 11 specialized cancer centers granted exemption from the Medicare Prospective Payment System (PPS) was similar to that of National Cancer Institute (NCI) cancer centers in terms of hospital characteristics, patient comorbidity burden, and cancer surgery outcomes, a new study found.

"These findings raise questions about why some cancer centers and not others are designated as PPS-exempt cancer centers and why there are different cancer quality reporting requirements for the various hospitals in the United States that provide cancer [care]," wrote Ryan P. Merkow, MD, MS, of the Feinberg School of Medicine at Northwestern University in Chicago, and colleagues in .

PPS-exempt cancer centers and affiliated hospitals are reimbursed on a "reasonable cost" basis instead of according to the diagnosis-related group (DRG) methodology used by NCI cancer centers and other cancer care hospitals. These hospitals are also exempt from having to report all process-of-care outcomes and patient experience measures to the Centers for Medicare & Medicaid Services (CMS).

estimated that CMS paid these exempt centers approximately $0.5 billion per year more than it would have reimbursed under the PPS system. The report concluded that Congress should require Medicare to pay these PPS-exempt cancer hospitals the same way it pays PPS teaching hospitals.

In an accompanying , editor-at-large Robert Steinbrook, MD, said the results 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."

"It makes little sense not to uniformly collect and publicly report cancer-specific quality measures for individual institutions," he continued. "This reporting should include all cancer centers and affiliated hospitals."

The retrospective study used data from the American Hospital Association Annual Survey and the U.S. News Best Hospital rankings to compare hospital characteristics and cancer-related services between 15 PPS-exempt cancer centers, 54 NCI cancer centers, and 3,578 other hospitals that provide cancer care. The researchers also compared postoperative outcomes in a sample of Medicare beneficiaries who underwent certain cancer operations: brain tumor resection, colorectal resection, cystectomy, esophagectomy, gastrectomy, liver resection, lung resection, pancreatic resection, and prostatectomy.

On average, PPS-exempt cancer centers had significantly higher U.S. News reputation scores compared with the scores for NCI cancer centers and affiliated hospitals (17.5 vs 2.6; P<0.001). Merkow and colleagues said these scores, although subjective, "may be a proxy for specific characteristics such as cancer-related services, specialists, trials, and technologies." However, no objective measure was significantly different between the PPS-exempts centers and the NCI cancer centers, including oncology patient volume, patient safety ratings, comorbidity burden, nurse staffing, U.S. News total cancer scores, or U.S. News survival scores.

The majority of patients (84.3%) who underwent one of the surgical procedures examined had the surgery performed at one of the other hospitals that provides cancer care; only 4.1% underwent surgery at a PPS-exempt center and 11.6% at a hospital affiliated with an NCI cancer center.

Fifteen of the 18 postoperative outcomes measures were similar between PPS-exempt centers and NCI cancer centers. However, patients treated at NCI centers were more likely to have:

• Postoperative sepsis (3.1% vs 1.7%; odds ratio [OR] 1.60, 95% CI 1.19-2.16, P=0.002)

• Acute renal failure (6.2% vs 3.9%; OR 1.64, 95% CI 1.26-2.12, P=0.01)

• Urinary tract infection (6.4% vs 4.0%; OR 1.58, 95% CI 1.26-2.00, P=0.002)

Among the possible explanations for this difference is that it may be a real difference or due instead to flaws in measures or a motivation for PPS-exempt hospitals "to capture billing codes for sepsis, acute renal failure, and urinary tract infection under the DRG payment model because these codes affect reimbursement," the researchers suggested.

Compared with other cancer-care hospitals, PPS-exempt centers had improved outcomes for seven of the 18 measures.

The researchers acknowledged that these results are limited because it is limited to Medicare beneficiaries, only looked at nine common operations, and only addressed short-term postoperative outcomes rather than other measures of quality.

Despite that, Merkow's team concluded that the results "suggest that the same cancer-specific quality measures should be collected for all cancer centers and hospitals in the United States, and that these quality measures should be publicly reported for individual institutions."

This type of reporting could "allow identification of more specific differences, if any, between different types of cancer centers, and an assessment of whether PPS-exempt status is achieving the intended goals," the team said.