The transition from traditional oncology reimbursement models to value-based models is quickly evolving and transitioning at a federal level. But many private payers are playing a waiting game, according to one expert.
“Medicare is using the MACRA MIPS payment models and the Oncology Care Model [OCM] five-year project to push changes in both oncology reimbursement and reporting,” says Dawn Holcombe, MBA, FACMPE, ACHE, president, DGH Consulting, director, Oncology Institute, NAMCP, and executive director, Connecticut Oncology Association. Holcombe will be presenting “Understand How to Adapt Market Strategies for Emerging and Existing Therapeutics to New Oncology Performance Models” at CBI’s 11th Annual Oncology Market Access Strategy Summit, in San Francisco, March 1.
Under the Oncology Care Model, physician practices will encounter payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients. “Many private payers are adopting a wait-and-see stance, especially since the calculation and data analytics are fairly complicated,” she says. “CMS is sending OCM practices patient level reconciliation and attribution reports, as well as total costs of care in aggregate and by categories on a regular basis. That type of reporting is not typical for private insurers, and will be slower to develop.
According to Holcombe, the industry has yet to see whether the OCM program will hit a snag when actual performance results start to be shared with practices in the next year.
“We might well see a problem with the MACRA model when providers get hit with the first of planned successive and incremental reductions in payment,” Holcombe says. “Initially, there is some change in focus on the part of OCM providers in choices for treatment therapies, but we are not likely to see a significant impact until the first performance results appear and the performance measures turn into real dollars -or lack thereof.”
The game changer
CAR T-cell therapy, which is promising but very costly, could become a key discussion point between payers, providers, and pharma as the development of value-based oncology models expands, according to Holcombe.
“I do believe that even the most promising new therapies will be viewed through a cost/benefit lens, by both providers and patients—to a degree that has not yet happened,” she says. “I don't see any sacred cows that will not be affected by this looming cost/benefit lens. Despite all the talk, major new reimbursement models are still mostly one offs or in process and not fully complete.”
Holcombe sees a growing focus on detailed tracking and managing patients and questioning both cost and benefit of treatment, by both providers and payers.
“I see different silos: some focused on the academic and scientific innovation, and other focused on the practicality of value and looking at the impact of medical choices on the finances of the patient and the provider under current or future performance models, and so far, ‘never the twain shall meet,’” she says. “As the years progress, and performance expectations tighten on providers, there will be ripples that impact on medical decisions.”
Consider this, says Holcombe: “CMS has basically set the expectation that their total spend for beneficiaries on average will be reduced by performance models from year to year. That flies in the face of recent history of medical treatments unfolding as combination therapies that layer on top of existing treatments or new treatments with their own significant price tags. I do believe that many cost/benefit lens will be sharpened and we will see hard lines being drawn. However, I don’t know what the outcome will be for patients. They may become part of the discussion since so much benefit design places significant personal cost burdens directly on patients.”
CMS initiatives are clearly stirring the pot, but the future results of those initiatives are not yet clear, according to Holcombe.
“We could see dozens of providers fail to perform under OCM or be penalized under MIPS, causing a cascade of new reactions,” she says. “I don't see private insurers adopting a universal approach, and the challenges for each of them to develop their own model that mirrors or doesn't mirror the CMS models mean we are still in for a long period of experimentation and transition.”