In July 2016, the Centers for Medicare and Medicaid Services (CMS) launched a payment model for oncology that aimed to achieve higher-quality care delivered at lower costs. Named the Oncology Care Model (OCM), this specialty model has shown promise, although barriers exist to achieving optimal outcomes for both patients and providers.
Participants include 176 practices and 11 payers, and the program wraps up in June 2021. At that time, CMS will continue to evaluate program successes and shortcomings as it decides whether to expand the OCM and launch new oncology payment models.
Notably, members of Premier’s Bundled Payment Collaborative who are participants in the model have shown success. The majority of physician practice members in Premier’s Collaborative earned performance-based payments in periods 1 and 2 of the OCM, outperforming peers by 100 percent and 27 percent, respectively. In working closely with OCM participants, Premier has observed three key benefits to the model and four recommendations to improve it.
The OCM Is Facilitating Provider-Led Oncology Practice Transformation
The program encourages practices to address numerous patient-focused areas, such as quality of care, patient satisfaction, and care coordination. The OCM has also increased the focus on the patient and improved access to data that support care delivery and better care coordination. This enables providers to be more proactive, establish a patient-centered practice culture, and leverage robust data to pinpoint improvement opportunities and support value-based payment arrangements.
Participants Are Proactively Managing Symptoms And Providing Patients With Improved Access To Avoid Emergency Department Visits
OCM practices have focused on increased patient access to care and addressed the underlying reasons patients seek care on an urgent basis. Providers have implemented same-day appointments, oncology-specific urgent care clinics, and telephonic nursing triage and protocols to provide timely, evidence-based care to manage symptoms from pain to nausea. This type of practice transformation is supported by the OCM’s enhanced services infrastructure payments.
Evolving To A Patient-Centered Practice Culture
Building person-centered models of care allows clinicians to more powerfully connect with their patients and caregivers. The OCM requires a focus on patient navigation, survivorship care planning and conversations with patients to establish goals of care, and other patient-centered approaches to care delivery. In addition, the introduction of early palliative care can improve the quality of life and ensure patient wishes and goals of care are known by the care team. The OCM has also facilitated an increased focus on the issue of financial toxicity and the need to provide financial counseling to patients.
Identifying Improvement Opportunities And Strategies Using Robust Data
Prior to the OCM, oncology practices had little insight into the care their patients received outside of their clinics. As part of participation in the OCM, practices receive adjudicated claims data from the entire continuum of care, which allows providers to holistically see all services their patients receive. More comprehensive data has helped practices determine areas of overuse. Identifying and addressing these opportunities simultaneously improves quality while reducing costs.
Enhanced data and information also allow oncology practices to begin discussions with commercial payers about value-based arrangements. Through the OCM model, some practices, including those in Premier’s Bundled Payment Collaborative, are already participating in value-based payment models with commercial payers.
Empowering Providers For Success Under The OCM
While the OCM has been beneficial in many ways, providers face challenges in the program that limit their ability to more fully transform oncology care. By addressing these challenges in the OCM and any future oncology models, the CMS can improve the initial model design and enable providers to successfully transition to accepting financial risk as they provide high-quality care. As the CMS evaluates the OCM and future oncology models, it should include four critical improvements to eliminate barriers to success.
Evaluate The Adjustment Methodology For Rapidly Evolving Treatment Therapies
On average, drug expenditures comprise 42.6 percent of total episode costs in the OCM’s six-month episode of care, per feedback reports that CMS shares with participating practices. This expenditure significantly impacts whether savings are generated for a single episode. The CMS currently uses a novel therapy adjustment factor to account for new therapies entering the market. The novel therapies adjustment methodology does not appear to sufficiently account for the impact of new cancer drugs, new indications for available drugs, or changes in the cancer-type mix of a practice’s attributed population.
The CMS should explore alternative methods to account for escalating drug costs without imposing undue burden on practices. The current adjustment factor fails to accurately account for quickly evolving evidence-based standards of care or the wide variation of treatment regimens for a specific cancer type. These regimens can fluctuate due to different disease stages and lines of treatment within an episode of care.
Possible solutions to address the rising cost of novel therapies include re-evaluating how novel therapies are accounted for (that is, retrospectively adjust benchmarks to account for the additional cost of novel therapies) or disaggregating the novel therapy adjustment and applying specific adjustments by cancer type and stage.
Refine Financial Incentives And Payments To Avoid Unintended Penalties And Promote Sustainable Clinical Transformation
CMS offers reimbursement to the OCM practices through a two-part payment system. One is a per-beneficiary monthly enhanced oncology services (MEOS) payment that pays for enhanced services provided to patients and aims to help build the infrastructure needed to manage and coordinate care. The second is a performance-based payment that allows practices to share in cost savings generated compared to a target based on historical spending. Once CMS develops target prices, it then applies adjustments for various factors specific to each episode of care. The target price that is created does not include any adjustments for the MEOS payment, which counts as an additional patient care expense in comparison to pre-OCM historical benchmarks.
The MEOS payment thus becomes an additional cost barrier that practices must overcome to perform better than the target price. CMS should consider options to lessen the impact of MEOS payments, such as updating the baseline time period to reflect the most recent performance period. This would ensure that target prices would be based upon a comparable baseline period (that is, included MEOS payments) and account for new treatments and standard of care upon target prices.
Also, many practices have concerns about their ability to sustain the staff levels and programs supported by MEOS payments once the program has ended. Therefore, CMS should incorporate MEOS-type payments in any new oncology alternative payment models.
Simplify The Attribution Process
Providers face challenges in identifying the patients who will be attributed to their practice as OCM beneficiaries, particularly those on oral treatment regimens. Providers have a record of a patient receiving chemotherapy infusions, which is one triggering event for an OCM episode. However, the other triggering event is when a patient fills a prescription for an OCM-initiating oral therapy, yet practices do not always have visibility into when or if this occurs.
The current attribution process is retrospective and attributes patients to practices that have the most evaluation and management medical billing codes within the episode time period. CMS should provide more frequent data (such as monthly instead of quarterly) to assist practices in identifying attributed beneficiaries.
In addition, the current attribution process has been cumbersome for practices to efficiently submit claims for the MEOS payment resulting in recoupment. To simplify the process and reduce administrative burden, CMS should provide a new option for participants to receive the MEOS payment along with the semi-annual performance-based payment. This option would allow CMS to determine the number of attributable beneficiaries and calculate the applicable MEOS payment, rather than rely on provider assessments of OCM-eligible beneficiaries.
Ensure Electronic Health Record Compatibility With Reporting Requirements
While the volume of quality measures associated with the OCM was initially high and burdensome to collect, CMS has been responsive to these concerns and reduced the number of measures. To further reduce reporting burden and encourage electronic transmission of necessary data, CMS and the Office of the National Coordinator for Health Information Technology should establish core clinical data for oncology care and measurement, and adopt standards for capturing and exchanging the data as part of routine care and business transactions. The goal is to reduce administrative and financial burdens on practices for data collection, file generation, and reporting.
Continuing The Cycle Of Programmatic Improvements
The promise of care transformation under the OCM has progressed, due to CMS’s willingness to make changes to the program after receiving provider feedback. The findings included above constitute the next phase of lessons learned and provide additional opportunities to improve the OCM and the design of future oncology models. By remedying these challenges, CMS can enhance model stability, encourage more providers to continue to participate and sign up for future oncology models, address unintended consequences, and reduce provider burden.
Premier continues to advocate for our members and encourages the adoption of laws and regulations that improve quality and value in health care. Stay up to date on Premier’s advocacy efforts.
This blog also ran in the Health Affairs Blog on April 22, 2019 10.1377/hblog20190417.733414
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