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.

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.

But patients who get enrolled in clinical trials are the cream of the crop, they are generally healthier than average, they are motivated and want to live longer, and they fight one step more than the average patient with the same disease and stage. Theoretically, practices that attract patients seeking clinical trials are potentially the ones whose patients will live longer and receive more lines of therapy. This can and will make such practices look more costly when compared with those that don’t participate in meaningful phase I, II, and III clinical trials. They will be penalized and unfairly so.

Speaking of the “fighter patients,” who would refuse to leave any stone unturned—even outside clinical trials&mdash;such patients will never quit as long as there is any potential that they can live another few days or weeks to see a daughter getting married or witness the first communion of a grandson. But when, finally, there is nothing else that can be done, such patients agree to go for hospice care, where the survival is numbered in days, not weeks or months, and this affects the OCM penalty, because the days a patient spends in hospice are a part of the equation. The longer the hospice time, the better boy you are, because it is assumed that earlier referral to hospice results in longer hospice days, a presumed fact that is very much in dispute.

The hospice length of stay is vastly variable depending on the practice and philosophy of a particular hospice. We at Gabrail Cancer Center have done an analysis of that. Generally, privately owned for-profit hospices keep the patient alive for a significantly longer period of time compared with the not-for-profit, which is usually hospital-owned. That variation between centers can have an impact on the OCM program evaluation and this disparity is totally out of the control of the treating oncologist.

The most formidable challenge still rests on hospitalization. I need to come back to this topic because it is as convoluted and political as it gets. When an increasing number of primary care doctors decided to relinquish their hospital privileges, hospitals got nervous about who would take care of the hospitalized patients and, more critically, how they would keep hospital beds full. The hospitalist program was the answer. Now, hospitals employ or contract with ED groups and an undeclared admissions quota is put in place, complemented by the hospitalist program, which serves both the owners of the hospitalists program and the hospitals. Of course, it is even more convenient if the hospital employs the hospitalists. It is very hard for the oncologists to control that scenario when their patients show up at the ED with a cough or sore throat. The ED looks for a reason to admit, and the hospitalist is happy to take on the task.

The OCM program is a good start on a path that is as rough as it gets in our healthcare system that needs reform, which can’t come from legislation such as Obamacare. The change has to come through gradual reform that is trial and error and that would work as long as the intent is honest and pure.

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The OCM program is a good start on a path that is as rough as it gets in our healthcare system that needs reform, which can't come from legislation such as Obamacare.

Nash Gabrail, MD

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The OCM Is Both Good and Questionable