The oncology model of care and its successor

Although the cancer model of care produced positive results, the value-based model of care cost Medicare money. Attention now turns to its successor, the Oncology Improvement Model.

The Oncology Model of Care (OCM) was introduced in 2016 by the Centers for Medicare & Medicaid Services (CMS) with the goal of improving the quality and coordination of care for cancer patients. It aimed to do this by bundling payments for care and encouraging collaboration between providers. Practices could bill Medicare for an Enhanced Oncology Service (MEOS) $160 per month for each beneficiary receiving chemotherapy. Participating practices were also eligible for retrospective performance-based payments (PBP) that were measured by financial benchmarks and quality metrics.

The program, which ended in June this year, included 126 firms and five payers. The latest program evaluation report, released in December 2021, covered six performance periods beginning July 1, 2016 and ending July 1, 2019. The report showed that practices participating in the OCM spent an average of $298 less per episode than a practice comparison group not participating in the model. Spending cuts have been concentrated in caring for patients with high-risk lung cancer, lymphoma, colorectal cancer and breast cancer. However, the difference of $487 per episode in spending for these cancers was offset by higher spending for low-risk cancers.

Additionally, the evaluation report found that once the MEOSs and PBPs of participating practices were taken into account, the OCM program cost, rather than saved, the Medicare program. During the first five performance periods (July 1, 2016 through January 1, 2019), the net cost to Medicare was $377.1 million, according to the valuation report. In no performance period did savings on episode payments exceed MEOS and PBP.

The Oncology Institute of Hope and Innovation (TOI) is one of the largest value-based oncology groups in the United States. “As strong believers in the benefits of value-based care, we support the premise of CMO and see it as proof that great outcomes can be achieved while maintaining sustainable costs. Through participation in the OCM, more practices have had the opportunity to implement value-based care best practices and see the potential for impact on patients and the healthcare system as a whole.

But Carole Tremonti, MBA, RN, vice president of clinical strategy for Project Ronin, a healthcare analytics and software company in San Mateo, Calif., says OCM hasn’t delivered the results it hoped.
many reasons.

“The first is that it was a concept with no process or method to apply it. This left it up to health systems to figure out how to make a complicated process work, without necessarily having the means to do so,” she says. “Where it gets even more complicated is that in the oncology space there are multiple players involved in treating a patient, plus their primary care physician, who is not necessarily in close connection to the medical oncologist, nor has access to the same medical file.This initially puts the whole process at a disadvantage.

Tremonti also points to the problem of measurement. “All health systems and providers struggle with measuring population-level data,” she argues, adding that “the EHR (electronic health record) doesn’t make it easy, and neither are those systems. more competent in statistics at the population level. To complicate this process, patients move. They don’t necessarily receive care in the same place or in the same system. For example, a patient may go to an emergency department (ED) or urgent care facility outside of their medical oncologist’s knowledge or data collection, making it difficult to intervene, says- her, and mentions “the complicated space of patient/provider communication.”

François de Brantes, senior vice president of episodes of care at Signify Health and member of the Managed Health Framework®, believes that the OCM has been an important pilot project to demonstrate how to involve specialist care providers.

“It showed that when specialty practices engage directly with an alternative payment model – as opposed to indirectly through a total population cost-of-care model – they begin to transform their practice and improve outcomes. for patients,” he said. “It also showed that upside-down models are never budget-neutral for a payer.”

There is evidence that MCO has beneficial effects on care. For example, one study found that the model resulted in decreased use of resources such as hospital admissions and emergency room (ER) visits and increased use of preventive services. It has also been found to improve communication between providers and lead to better coordinated care.

“The biggest impact of the OCM has been to force the systematic collection and reporting of patient-level data and to match costs to those patients,” de Brantes said. “This feedback that matched clinical data with claims data is really essential for gaining insight into complex conditions such as cancer, and program practices have learned a lot about treatment variations, treatment costs, and patient outcomes.”

Miller notes that by sharing responsibility for the total cost of care for a patient, the OCM encourages programs that better serve patients by focusing on prevention and symptom management.

“Patient navigators and symptom assessment have been shown to be extremely beneficial, reducing emergency room visits and associated risks and costs,” he says. “Furthermore, the participating practices have benefited from the rich data provided by the OCM. At TOI, we’ve used this data to continually improve quality metrics, and we imagine other practices are doing the same. »

TOI saved Medicare about $4,000 per episode during the most recent performance period, according to Miller. “This is particularly remarkable given the relatively small percentage of our patients who qualify for the program,” he says. “TOI is already implementing similar measures through managed care and capitalization contracts which make up the majority of our practice. »

Ashley Tait-Dinger, MBA, director of analytics, alternative payment models, and finance for Florida Alliance for Healthcare Value, believes the CMO has been effective because it has integrated additional services and touchpoints that n weren’t considered in the traditional model of care. How providers implement these services and how they are paid are issues that need to be addressed, she says.

The successor

OCM’s final performance period ended on June 30, 2022. One of the options CMS’s Center for Medicare & Medicaid Innovation (CMMI) considered was to simply stick with OCM, but to make a two-sided risk model, which means firms could face financial problems. penalties if they fail to meet financial and quality criteria. “It created an immediate and very negative reaction from oncologists across the United States,” says de Brantes. “They argued against the downside risk given the design of the model, which included all costs of care for the beneficiary, not just cancer costs, as well as chemotherapy costs. As such, Oncology Care First (OCF), as it was called, was put on hold. The assumption of downside risk – when and how much – has been a major problem with other value-based compensation arrangements, including responsible care organizations.

On June 27, CMS announced the successor program, which it calls the Oncology Improvement Model (EOM). Despite apprehensions about downside risk, EOM includes downside risk from the start, although there are two tracks.

Basically, EOM is very similar to OCM. It will be voluntary, not mandatory (some experts say voluntary programs will not be effective in delivering values-based care). The MOE has the same basic structure of six-month episodes of care. Practices will still receive MEOS payments for providing enhanced services, although as proposed they would receive $70 per month instead of $160, and be eligible for PBPs.

However, there are also important differences. EOM will cover Medicare patients undergoing chemotherapy for the most common types of cancer (lung, breast, multiple myeloma, etc.). However, according to a comment by Stephen Schleicher, MD, MBA, chief medical officer of Tennessee Oncology, EOM excludes cancers treated with hormone therapies only, such as low-risk breast cancer. Schleicher said reducing the cancer treatments that are covered may prevent some of the variability seen in the CMO depending on the mix of cases.

The EOM also includes new requirements for electronic patient-reported outcomes, patient-provided data on side effects and compliance that are meant to improve care by creating a continuous feedback loop of information. Schleicher said the addition was welcome, but also cautioned against adding burdens of reporting on practices.

In its MOE fact sheet, the CMS highlighted that providers participating in the payment model will need to screen patients for health-related social needs (HRSNs), such as lack of transport for medical appointments. perfusion, which may contribute to disparities among cancer patients. The HRSN screening requirement is part of the Biden administration’s effort to have CMS programs of all kinds consider health care disparities and ways to address them.

CMS is accepting applications for EOM until the end of September 2022. The program, which as proposed will last for five years, is not expected to start before July 2023. Some supplier groups have said that the one-year gap between the end of CMO and the start of EOM will be a hardship because the practices will bear the costs without the benefits of the model.

Miller, speaking ahead of the release of the MOE, predicted that health equity would be front and center: “I expect to see an increased focus on health equity, which would be a welcome addition and a natural progression to ensure these programs work for all patients. ”

John Griggs, senior director of solutions consulting at Managed Markets Insight & Technology, said ahead of the EOM announcement that clearer guidelines and ongoing training for all key stakeholders are needed. “It would allow for faster adoption and stricter enforcement,” he said. “And once implemented, clear metrics need to be defined to track success and report results of programs by payers and oncologists.”

Keith Loria is a freelance medical writer in the Washington, DC area.

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