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The goal of the Oncology Care Model is to incentivize high-quality, coordinated care with an episode-based payment model that emphasizes patient access and navigation.
Robert “Bo” Gamble
The thought of joining the Oncology Care Model (OCM) didn’t scare Tracey F. Weisberg, MD. She had participated in the Community Oncology Medical Home (COME HOME) program, an earlier model of patient-centered care, so OCM seemed like a natural next step for her practice, New England Cancer Specialists of Scarborough, Maine. Both programs aimed to focus practices on payment based on value of care provided rather than volume of treatment. After adopting strategies to increase the value of care at New England Cancer Specialists through COME HOME, Weisberg considered her practice ready for the OCM, and she greeted the pilot value-based payment model with optimism.
"The idea was a natural for us coming out of COME HOME. It built upon the expectation of quality and value that we had already instilled in our staff and patients, so it was a natural process for us," Weisberg, said.
In the words of a recent Tuple Health study on OCM enrollees, Weisberg’s practice would be considered a “high-expectations participant.” The study, commissioned by the Community Oncology Alliance (COA), is the first to analyze the reasons 187 practices have chosen to participate in the OCM.1 Study authors Celeste Roschuni, PhD, MS, and Basit Chaudhry, MD, PhD, of the healthcare technology startup Tuple Health in Washington DC, identified 4 types of participants: dubious, reluctant, high-expectations, and pathway.
“The Tuple Health study helped us realize that a successful reform model will need to appeal to all 4 types of OCM enrollee,” said Robert "Bo" Gamble, BS, COA’s director of Strategic Practice Initiatives. “Each gravitates to a certain type of communication.” Therefore, the OCM’s administrator, the Center for Medicare & Medicaid Innovation (CMMI), must focus on communicating effectively with OCM participants for the 3-year pilot payment model to be successful, Gamble said.
The goal of the OCM is to incentivize high-quality, coordinated care with an episode-based payment model that emphasizes patient access and navigation (FIGURE). Practices receive monthly per-patient payments to cover the high-touch elements of this form of care and additional costs involved in elevating quality. There are 6 major requirements (TABLE).
However, physicians and practice administrators have stated that succeeding with the OCM has been a challenging mixture of technological difficulty and cultural adaptation. Although some say that it has worked out for them, others doubt that it can succeed for all practices. At the same time, groups such as the American Society of Clinical Oncology and COA have lobbied for collaborative models of care that are better tailored to oncology practice and include more input from oncologists themselves.
CMMI, the experimental arm of CMS, started the OCM in July 2016 with 195 practices and 17 payers enrolled as participants. By mid-February 2018, those numbers had dropped 4% and 1.7%, respectively, to 187 and 14.2 “They’re expecting to change the way healthcare’s been delivered for the past 52 years,” Gamble said. “They can’t do that if they’re not thoughtful and careful and cautious in helping people make this transformation in their thought process.”By analyzing 35 responses to a survey they conducted, Chaudhry, Tuple Health’s CEO, and Roschuni, the startup’s lead researcher and study designer, identified 4 OCM participant types. Practice members’ mind-sets ranged from doubtful to eager, the duo found. It’s important to understand these states of mind, Roschuni said, because “each one will have a different path [of success] to value-based care.” From dubious to pathway (forward-thinking), the predominant attitudes represented “the least engaged to the most happy,” Chaudhry said.
Dubious participants came to the OCM with no prior experience in value-based care programs. Their loyalties lie with the fee-for-service model, which rewards volume of care, but they see the transition to value-based care as inevitable and don’t want to “be left out in the cold,” as one practice told a Tuple Health interviewer.
Despite this pragmatic approach to enrolling, dubious participants are dogged by anxieties about the OCM. They see the program as unfair, depriving them of funds and forcing them to take responsibility for elements of a patient’s health that are out of their control. The OCM holds practices accountable for the costs of care incurred at their sites or at an emergency department a patient might have visited because the oncologist’s office was closed. “This quote is very telling: ‘I think it’s a way to figure out how to pay me less,’” Roschuni said, quoting an interviewee.
Dubious participants do appreciate aspects of the OCM that enhance patient care, the Tuple Health team found. Several participants who fit the “dubious” mold liked the improved record keeping related to OCM participation, and others appreciated the nurse navigators that the OCM required practices to hire to help patients overcome healthcare system barriers. The next type of OCM enrollee, the reluctant participant, tended to join the program because 1 person at the practice championed the idea of value-based care. The rest of the practice was more ambivalent: Although some employees followed the advocate’s lead, others remained skeptical—or, as 1 value-based champion put it: “Some of them will be very excited with you, and some of them look at you like you have 2 heads.”
“The reluctant participant is similar to the dubious participant in that they have very little experience, but their motivation is more internal,” Roschuni said. “They have someone who thinks, ‘We want to stay ahead of the curve. This is the future of healthcare—let’s go do this.’”
At reluctant-participant practices, the valuebased champions tend to shoulder most of the burden of readying the practice for the OCM, Roschuni said. If someone is going to figure out how to keep patients out of the emergency department and forming relationships with local hospitals, it will likely be that person, she said.
The third type of participant—the one with high expectations—has some experience in value-based programs going into the OCM. Most likely, that experience was successful, given that this participant sees the OCM as a way to reap rewards for how it has prepared for value-based care. “We think of ourselves as a high-quality provider, so any model that rewards quality, we think we would shake out ahead,” 1 high-expectations participant told Tuple Health investigators.
This mind-set helps practices succeed within the OCM, but it also makes the program’s complexities “particularly difficult to come to terms with,” Tuple Health investigators wrote. These participants tend to be surprised when they have trouble navigating certain OCM elements because of their perception of being highly efficient and valuebased already, investigators wrote.
The final type, the pathway participant, is the opposite of the dubious participant, motivated by internal rather than external reasons. This participant has fully switched over to a value-based way of thinking about healthcare delivery. “They think much more in a value-based way, because they have had a lot of those internal discussions in the past,” Roschuni said. “They’ve already done a lot of work to shift the practice toward that mind-set.”
If any practices will be “dragging payers into value-based discussions and contracts,” it will be these, Roschuni said. “We saw them having a path they had defined for themselves to become a value-based provider.”The single biggest factor that influenced practice members’ mind-sets going into the OCM, Tuple Health investigators found, was their level of previous experience in value-based programs. This had more impact on a practice’s ability to be successful in the OCM than its size, scope, geography, or patient population did, investigators found. “There’s a general sense that the program is designed for larger, more advanced practices and health systems. However, even these practices may be struggling,” Tuple Health investigators said in a COA presentation.
It appears that CMMI designed the OCM to appeal to the average practice, the investigators said, but the startup’s research showed that there is no such thing as an average practice. “Some stakeholders will need new or different communications, education, or guidance [to be successful in the OCM],” Gamble said. “COA is finding that although a plan or model may be excellent in theory, the key to success will be a thoughtful and strategic implementation. Communication needs to be frequent, organized, and even repetitive, if necessary, so all types of stakeholders can embrace and own the model.”
Tuple Health investigators anticipate that more practices will adopt the high-expectations mind-set as they test the waters of value-based payment models. Until then, the dubious and reluctant participants may need a little help, especially considering forthcoming changes to the OCM. Initially, practices receive performance-based payments for reducing expenditures below target levels, and there is no penalty for expenditures over target amounts. CMS hopes to move practices toward an advanced payment model in which they assume downside risk, making them responsible for refunding Medicare for expenditures over the target amount. That second track system is not yet mandatory.
“One of the things that’s going to be interesting with the OCM is what happens when it becomes a track 2 model. Currently, it’s all upside risks. What happens when it’s upside and downside? That’ll be interesting to see,” said Anne Hubbard, MBA, director of health policy at the American Society of Radiation Oncology.
Tuple Health’s Kavita Patel, MD, MS, considered what’s next for the OCM and its participants in her COA Payer Exchange Summit presentation, “OCM 2.0: The Journey Ahead,” delivered in October 2017 at Tysons Corner, Virginia.3 To prepare, she relied on some of the same interviews used by Tuple Health to identify the 4 categories of OCM participant. Patel concluded that OCM participants want to deliver high-quality care, but they do not want burdensome data-reporting requirements or to have the cost of a drug influence whether a patient can use it. OCM participants echoed that sentiment in interviews with OncologyLive® last fall. Most, however, were optimistic about the model’s future, as long as CMMI continues to respond to practices’ concerns. “We’re a year and a half into the OCM. It’s a new process altogether, so it’s a huge learning curve, but I do feel we’re probably on the right track toward accomplishing the overall purpose of the program,” said Kashyap Patel, MD, of Carolina Blood and Cancer Care in Rock Hill, South Carolina. Patel serves as COA’s secretary.
The overall purpose of the program—to improve patient care while reducing cost—is crucial, Chaudry added. Fee-for-service hasn’t been working, and it’s time for a change, he said. “We’re investing close to 20% of the [gross domestic product] on healthcare, and the outcomes we’re getting aren’t that much better than [those of] Canada or Singapore or Sweden,” which spend less per capita than the United States, Chaudhry said. “Why are we spending so much on this, given that?”