The Oncology Care Model and Its Heir Apparent

March 12, 2020
Jennifer Gershman, PharmD, CPh

MHE Publication, MHE March 2020, Volume 30, Issue 3

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 assessed

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.

Related: CVS Health Launches New Approach to Oncology Management

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:

  • Broader population. OCM limits the MEOS payments to practices to patients who are receiving chemotherapy. OCF would expand that population to include patients receiving hormone treatment. Patients not getting any cancer-related drug but under active surveillance or whose care is being otherwise managed by an oncologist would also be counted. This proposed expansion pertains only to the monthly payments, not to the patient population assigned to practices for the purpose of possible performance-based payment.

  • Pooling of patients. In OCF, practices could team up and pool their patients for the purposes of hitting benchmarks for the performance-based payments.

  • Electronic patient-reported outcomes. Under OCM, the enhanced services were 24/7 access to a clinician, patient navigation, preparation of care plans, adherence to guidelines, use of certified electronic health record, and using data for continuous quality improvement. OCF adds electronic patient-reported outcomes, or ePROs, to that list. CMMI’s informal request for information says ePROS can be used to monitor patient symptoms and identify high-risk patients.

  • Access to more timely claims data. Keely Macmillan, a senior vice president at Archway Health, a healthcare consultant that specializes in bundled payments, says that under OCM practices get claims data on a quarterly basis, which creates too much of a lag between when the care is delivered and steps that practices might take to address practice transformation issues. Macmillan says CMMI is committed to providing OCF participants claims data more frequently.

  • Expansion of care covered by monthly payments. As proposed, under OCF the monthly payment would include payment for enhanced services and an “administration component” that covers administration of drugs. OCM’s monthly payments are designed to cover just the enhanced services. Macmillan says it is still unclear whether additional services such as imaging or lab services will be included in the OCF monthly payments, but the intent is to make a greater share of the payments to practices prospective rather than fee for service.

  • Risk stratification by cancer type. Under OCM, CMMI does not set monthly payments or novel therapy adjustments specific to cancer type. Macmillan says Archway’s analysis of data from 20 OCM practices revealed problems with lumping cancers together in that way. For example, lung cancer cases were strongly correlated with negative performance-based payments, an indication of a model that doesn’t properly take into account the care needed. Likewise, colorectal and small intestine cancer were correlated with positive performance payments. As proposed the OCF monthly payment would take into account the type of cancer and whether the patient received chemotherapy or hormonal therapy. The OCF informal request for information also floats the idea of dividing a subset of cancers (breast, bladder, prostate) into highand low-risk categories for the monthly payment “in recognition that spending patterns are significantly different for high-risk patients receiving chemotherapy and low-risk patients receiving hormonal therapy.” The informal RFI also suggests calculating novel therapies adjustments by the type of cancer.

  • Downside risk. The OCF would have three risk tracks, two with two-sided risk right off the bat. The upside-only track would be available only for two performance periods.

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,” François 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. 

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