The successor, Oncology Care First, will likely include two tracks with downside risk right from the start.
Cancer is not quite the ferocious killer that it used to be. Millions of Americans are living with cancer, not just dying from it. Reasons for the diminishing death rate include lower smoking rates, earlier detection of some cancers, and advances in treatment.
But the treatment advances are coming at a high price. Treatment costs can easily exceed $100,000 a year. In response, CMS and commercial insurers are establishing alternative payment models, which, in theory, are supposed to slow down the stampeding costs while protecting, and perhaps even improving, the quality of cancer care.
The Oncology Care Model (OCM) developed by CMS’s Center for Medicare and Medicaid Innovation (CMMI) is certainly the highest profile of these alternative payment model. In November, CMMI announced a successor program called the Oncology Care First (OCF) that for the most part builds on OCM and might push episode payment for cancer care more fully into the mainstream of healthcare. Importantly, OCF will most likely include two tracks that would include downside risk right from the start, and the third will be upside-only for a limited time. But some experts are arguing that value-based cancer care would be better served by a program involving just four of the most common cancers while also changing how costs are gured so they would relate solely to cancer care.
OCM is a five-year pilot program that began in July 2016 and is scheduled to end next year. CMMI says 175 practices are currently participating Each episode is six months long and is triggered by a patient receiving either oral or intravenous chemotherapy. Under OCM, care has continued to be paid for on a fee-for-service basis: This is not a prospective payment program.
But OCM has two types of payments that are supposed to serve as an incentive for controlling costs and improving care. Participating practices are paid a “monthly enhanced oncology services”-MEOS, for short- payment of $160 per patient for care coordination. They are also eligible for shared savings payments if they beat episode-based financial benchmarks and met quality improvement targets. OCM also requires participating practices to provide a number of services, including around-the-clock access to a specialist who has real-time access to patient medical records, care plan documentation, and pharmacotherapy based on nationally recognized clinical practice guidelines.
Views differ on OCM. Some see a well-intentioned start to episodic payment but also a work-in-progress.
“The OCM is an attempt to enhance the oncology care, but I am not sure it’s accomplishing the goal yet,” says Luis Raez, MD, FACP, president of the Florida Society of Clinical Oncology, and chief scientificofficer and medical director of the Memorial Cancer Institute in Hollywood, Florida.
Raez says OCM quality standards have led to improvements in care but that the program needs an upgrade. Enough time has passed-and data collected-for researchers to begin studying OCM. An evaluation of its first year that was commissioned by CMMI identified declines in the use of intensive care units and emergency departments by patients of OCM practices, but not much, if any, effect on the lowering of costs. CMMI gave some details about OCF when it unveiled the program with an “informal request for information” in November.
Here are some of the important diferences between OCF as proposed and OCM:
OCF has been characterized as a thoughtful upgrade of OCM-a tweaking that will solve some problems. Not everyone sees it that way.
“I like that OCF is moving to downside risk, but otherwise there’s not a lot I like about that program,” FranÃ§ois de Brantes said in an email to Managed Healthcare Executive.
De Brantes, a senior vice president at Signify Health, says that by emphasizing total cost, OCM and OCF mean oncology providers stand to gain (or lose) payment based on services that have nothing to do with their patients’ cancer care. He also said the programs don’t adjust enough for dierent types of patients and the dierent types of cancer.
An article published on the Health Aairs blog post in December, de Brantes and four colleagues argued that OCF could be improved by focusing on breast, lung, colorectal, and prostate cancer, partly because the treatment strategies for those cancers are well known and established. Limiting the program to those four cancers could also “sharpen the eorts to measure quality in a more meaningful way,” they wrote. De Brantes and his colleagues also made a case for focusing the model on the most eective, appropriate treatment for patients, not necessarily its price, which, they said, may be largely out of the providers’ control.
Jennifer Gershman, PharmD, CPh, is a pharmacist and medical writer residing in South Florida.