Nash Gabrail, MD
Oncologists and their staff are always suspicious of any CMS program, and rightly so. The skepticism is founded in the history of CMS and its policies favoring hospitals over independent practices. In fact, the word “favoring” is an understatement because of the preferential fee schedule for outpatient services and the discounted drugs hospitals obtain through the 340B program, not to mention other unfairness.
But that doesn’t mean that we don’t give CMS the benefit of doubt: certainly, the Oncology Care Model (OCM) program seems to be well thought of and well designed, so far. It seems to me that CMS has not been able to significantly curtail emergency department (ED) and hospitalization costs. This is because of the many and excessively profound political mazes the agency has to navigate. In simple English, CMS is stymied by the difficulty of surmounting the power of lobbies and special interest groups. Outflanking the powerful American Hospital Association could only be achieved through programs like OCM, which punishes or rewards practices based on cost-containment measures, at the top of which rank ED visits and hospitalization. Brilliant. But this is not an unqualified endorsement of the OCM program or a prediction that it will succeed. After all, it is a government program like any other that starts with good intent but results in catastrophe. Again, the benefit of doubt is in order. Here are some of the concerns I have based on the experience we have with the OCM at our cancer center.
Among the parameters used to calculate reward for the practices is the rate of ED visits and hospitalizations. Is there room in here for patient navigation? Most oncologists have been diligent in keeping patients away from the hospital. Many already have extended weekday and weekend hours. A compounding factor in this parameter is that practices are evaluated based on their prior practice style. If you have been doing your best, how much better can you get?
People involved in the Medical Home model would tell you that, despite all the efforts and hoops they jump, there are patients who are “addicted” to ED visits and any ED visit has a high likelihood of ending up in hospitalization. Most of us had concerns about using practice historic data as the benchmark to calculate the promised shared savings check. That brings me to the subject of the incentive, which is a tricky one.
A Pat on the Back
The OCM program promises practices a financial incentive for the “Good boy!” performance. One problem with that government promise is, it is one-sided: they analyze the data and decide that physicians have no say, no rebuttal, nothing. The contractor who is building you a house says, “Trust me, I will be honest with you. I will charge you what is fair after the work is done.” You know the story if you have ever built a house without having exact details of the plan or knowing the cost of the nails and bolts. There is a potential problem when the payer is the one who decides whether special benchmarks are met or not, especially if there is not one single benchmark but many with different target values in the calculation of performance. Performance in the OCM is based on cost containment, which includes lowering hospitalization, the cost of drugs, and the amount of testing. This brings us to whether, through the OCM, CMS is trying to restrict the scope of service.
Second-line therapy for non–small-cell lung cancer, according to the experts and guidelines, can range from Taxotere to Alimta to Opdivo. The cost differences among those options are in the thousands of dollars. Is CMS trying to deter us from using the better and safer yet much more expensive agents to achieve a benchmark that will reward us for a Good boy! performance? The OCM seems based on the assumption that oncologists chose more expensive drugs for a better profit margin, but even if that is true, most of the agents chosen are more effective, cause fewer side effects, and provide better quality of life. We really have to think about this more deeply. The taxpayers’ money is there to serve our fellow citizens, especially the most vulnerable ones—patients with cancer.
One area that the OCM model has miserably failed to address is clinical trials participation. There are pros and cons to inclusion of clinical trial patients. The pros are better medicine for the patients because they are treated with futuristic drugs. Second, studies have shown that patients on clinical trials live longer and have better quality of life regardless of whether trials are successful or not.