With just 2 more years to go in the Oncology Care Model, CMS is proposing a next-generation payment system that would include more private payers and hold practices more accountable for quality and costs of care.
With just 2 more years to go in the Oncology Care Model (OCM), the Centers for Medicare & Medicaid Services (CMS) has proposed a next-generation payment system that would include more private payers and hold practices more accountable for quality and costs of care.1
CMS says the new model, Oncology Care First (OCF), would build on the lessons learned from the 5-year OCM, which terminates in 2021. OCF, which is being designed through the Center for Medicare & Medicaid Innovation (CMMI), would start in January 2021. A brief public comment period offered in November 2019 allowed for feedback from potential stakeholders, including practices that have been involved in the OCM. Participation in the OCF model, a 5-year program, would be voluntary.
OCF would qualify as an “advanced payment model” under which eligible oncology practices could earn higher reward payments for improving costs and quality of care. It would include both 1- and 2-sided risk, which would entail performance payments without penalties for failure to meet targets or performance payments combined with financial penalties, respectively.
Like the OCM, the OCF model would include financial incentives to reduce reliance on fee-for-service (FFS) care, which has been blamed for low quality relative to cost across the Medicare spectrum, and it would increase accountability for the quality of outcomes in oncology care.
The initiation of planning for the OCF model took oncology clinics by surprise. Many of them were already trying to decide whether to enter a higher-risk phase of the OCM or exit the program. The deadline for that decision was December 3. The Community Oncology Alliance (COA) responded that it was burdensome to contemplate a new model design at such a critical time in the OCM.
As a result of the OCF announcement, COA said it has decided to temporarily withdraw from consideration a rival oncology care model called OCM 2.0, which it has been formulating for a number of years. Oncology groups have contended that the OCM is not well tailored to oncology practice. COA has stated that OCM 2.0 is a streamlined version that includes a way to address the increasing cost of cancer agents.
“The COA team has made the difficult decision to withdraw our application for the OCM 2.0 model to the Payment Model Technical Advisory Committee (PTAC). The PTAC process needs to be addressed, as it appears getting PTAC approval is not leading to CMMI funding,” COA stated.2 PTAC advises the Secretary of Health and Human Services on physician-focused payment models.
COA asked CMMI to implement elements of the Making Accountable Sustainable Oncology Networks model, which is approved by PTAC and designed to decrease overall Medicare spending for oncology patients while improving the quality of care.
The alliance will continue refining the OCM 2.0 as a “a viable universal model not just for Medicare fee-for-service, but for all payers, including Medicare Advantage, insurers, and employers,” COA said.
ASCO Updates PCOP Model
The American Society for Clinical Oncology (ASCO) proposed its own alternative payment model, the Patient-Centered Oncology Payment (PCOP) model, in 2015 and updated it in 2019.3 Like the OCM 2.0 and the OCF, the PCOP model is designed to promote valuebased cancer care, and it incorporates lessons learned from the OCM. The PCOP model comprises an oncology medical home framework, a performance-based payment system, and clinical pathways that follow ASCO criteria.4 A key distinction is that the PCOP model does not hold oncologists financially accountable for costs of drugs.
However, unlike the OCM 2.0, the PCOP model would not supplant the OCM. ASCO said it envisions the model as a complementary system that would be “deployed within a state or local community, alongside primary care, surgical, and radiation models.”3 This is based on the idea that the PCOP model is not a one-size-fits-all framework.
In November, ASCO said that it would recommend the financial model to CMS and CMMI in response to their call for comments about the next steps for value-based cancer care following the completion of the OCM in 2021. “PCOP offers a way to expand on the OCM experience and would be an appropriate next step in innovation,” ASCO said.4
Jeffrey Ward, MD, past chair of ASCO’s Government Relations Committee and a leading contributor to the PCOP model, told OncologyLive® that it “contains many elements of the OCM, but builds on it in a way that accommodates participation by a [broader] range of practice sizes and settings.”
Ward added that the PCOP model’s use of pathway compliance as a performance measure is an important distinction of the PCOP, as is its exclusion of drug costs from bundle pricing. “Physicians don’t control the launch price of drugs, but they do control how they are used. The ASCO model recognizes that reality,” Ward said.
Both physician group practices and hospital outpatient departments would be enrolled in OCF. Essentially, the model would test whether cost accountability combined with systems that offer practices predictable revenue streams would improve care coordination and management for Medicare beneficiaries with cancer or cancer-related diagnoses, CMMI said. As with the OCM, the goal is also to control overall expenditures under the Medicare program.
As currently planned, the OCF model would give practices a monthly payment for Medicare FFS beneficiaries with cancer or who have received cancer-related diagnoses. These payments would cover evaluation and management services, a separate category of “enhanced services,” and drug administration services, according to CMMI.
Concurrently, practices would be held accountable for “total cost of care” for Medicare costs, according to CMMI. These include costs of drugs for Medicare beneficiary Part B or Part D chemotherapy drugs. Like the OCM, OCF would use financial penalties and rewards to incentivize good performance. These are called performance-based payments.
CMMI said in the announcement that the OCM has had “an increasingly positive impact” on acute care usage and quality of care. In addition, inpatient admissions and intensive care unit stays during patients’ last month of life have been reduced.
A practice would be allowed to include in the OCF model all Medicare FFS beneficiaries who are eligible for Part A (inpatient hospital expense) and enrolled in Part B (medical insurance) with Medicare as the primary payer, provided they are under treatment for cancer or a cancer-related diagnosis.
Eligible patients would be those who receive chemotherapy, hormonal therapy, or no cancer-related drugs, such as those under active surveillance or cancer survivors who continue to receive care management from an oncologist. In this way, OCF would differ from the OCM, which covers only patients who are receiving chemotherapy. “Our intent would be to support oncology practice improvements designed to benefit a practice’s broader cancer population,” CMMI said in a release.
For purposes of payment, chemotherapy treatment would be divided into 6-month episodes of care. This is also a standard feature of the OCM (Figure 1).
CMMI says it hopes that private payers and state Medicaid agencies will become partners in the effort by aligning their own value-based oncology payment models with OCF. “Incorporation of multipayer alignment within the OCF model would be expected to reduce costs and improve the quality of care for Medicare beneficiaries through improved ability to leverage whole practice transformation, reduce administrative burden, and align incentives across a participating practice’s patient population,” CMMI said.
CMS would establish a range of 7 standards for improved care, most of which are already a feature of the OCM (Figure 2). ”Based on OCM experience to date, we believe that they continue to be critical for high-quality care,” CMMI said, adding that the use of electronic patient-reported outcomes is intended to enhance care coordination.
model, CMMI suggested that the emphasis on cost savings would not be allowed to impair quality of care. “The potential OCF model would include quality measures that are tied to payment to ensure that the incentive to reduce costs is balanced with an incentive to maintain or improve care quality,” CMMI said.