Rough Start for Oncology Care Model

Robert “Bo” Gamble

Many oncology practices were motivated to join the Oncology Care Model (OCM) in order to keep up with the evolution of value-based care. But when the Center for Medicare & Medicaid Innovation (CMMI) started telling practices that their applications had been accepted, it was panic time for some, says Robert “Bo” Gamble, director of strategic practice initiatives for the Community Oncology Alliance (COA).

Officially launched this month, the OCM is designed to gradually introduce a risk-sharing arrangement that will put the pressure on practices to use their own Medicare and Medicaid billing history as the starting point for cutting costs and improving care. Not only that, practices will be expected to make improvements in coordinating and managing patient care with other providers. All of this includes an opportunity to share savings that are hoped for through this program. Eventually, oncology practices will have to undertake more revenue risk in order to avoid becoming subject to CMS’s new Meritbased Incentive Payment System.

Months ago, a core group of concerned practice representatives met with COA and went over the OCM. They were advised to create a brief list of major concerns they had about meeting the goals of the OCM. “We had about a dozen people, and they gave us a list of about 120 top priorities,” Gamble recalled. That prompted an “Oh, wow! This won’t work!’” But that was just the starting point. Gamble and others decided to pool their resources and get answers to the questions about how to make the OCM successful.

They created their own model that converted the CMMI OCM documents into a financial tool that could assist with budget requirements for OCM participation and also serve as a financial performance model. This collaborative resource was in turn shared with the 196 oncology groups— including hospitals and academic research centers—that have been accepted into the OCM program. “The OCM participation agreement includes some very specific conditions that if not followed will exclude the invitee,” Gamble said. “Most of these conditions were consistent with CMMI’s preliminary guidelines. However—and it may be due to wording or inadequate explanations—some teams discovered they were not in compliance and were scrambling at the last minute to determine how they could meet these criteria.”

Alternative Payment Models Are Not Going Away

Gamble indicates that the OCM Support Network, which COA has formed, has established a closed listserv—or e-mail notification system—and a bulletin board, and is holding monthly conference calls to address OCM difficulties. Also, a participant website will be created to house resources and documents. CMMI went public late last month with the names of the 196 practices and 17 payers that have agreed to be the first subjects in this latest alternative payment plan. The agency would not consent to an interview about the launch or the program. Practice administrators who spoke with Oncology Business Management about the transition said their primary concerns all along have been that the complexity of participating in a program of this type has been compounded by the difficulty of interpreting instructions from CMMI and its parent government agency, CMS.However, there was general agreement among them that value-based programs are going to be a fact of life in the oncology world from now on. “It is our view that value-based care in some form or other is the basis for how reimbursement will be in the future, and we want to be on the front end of learning how to do it and how to optimize it,” said Barry Russo, CEO of the Center for Cancer and Blood Disorders (CCBD) in the Dallas-Fort Worth area of Texas.

There were other reasons for joining, too. Shawn Kienert, CFO of Fox Valley Hematology Oncology in Wisconsin, said it was partly altruism and peer pressure that motivated his practice to join the OCM. The OCM was viewed as “a really progressive idea.” In addition, the OCM offered a way to ward off the competition from other practices in the neighborhood, Kienert said. “If the guy across the street is going to lower his fees and I want to maintain my patients, I need to find a way to lower my fees to match.”

CCBD has struggled to interpret the OCM requirements and figure out how to make it all work, said Russo. That’s despite the fact that CCBD has already been working on value-based programs with UnitedHealthcare and Aetna and was involved in an Oncology Medical Home (OMH) pilot in 2012.

“What we’re finding with the OCM is that the biggest challenge is gathering the information on quality, clinical, and even demographic data that CMS is requiring us to report on a consistent basis,” Russo said. That information has been available in piecemeal format, but not in the automated stream that CMS has requested.

For Hematology-Oncology Associates of Central New York, the transition has been aided by prior experience with the OMH and the Quality Oncology Practice Initiative from ASCO. “We have access to 24-hour care, we have patient navigators, we have electronic health records,” said Lynn Wentworth, who was hired specifically to help implement the OCM. “There were some processes that had to be tweaked, but it was understanding which direction Medicare wanted us to take those processes,” she said. For her practice also, the first hurdle was learning how to interpret CMS and its guidance. “Once we got our questions answered, then we were able to progress to building our infrastructure—to close the gaps that we might have had in meeting all of the requirements of the program.”

MEOS Payments Come with Challenges

Both Russo and Wentworth said the CMS requirement for fully engaging the Institute of Medicine’s 13-point care plan for patients was a bottleneck in terms of insufficient guidance and the need for combining disparate elements. The care plan, which is shared with patients, covers such things as the treatment plan, anticipated therapies, instructions for managing treatment adverse effects, and survivorship planning. “Most of the points in that care plan were not specifically outlined,” Wentworth said. For example, her practice was looking for more explanation of how broadly a disease prognosis should be defined for patients.Practice administrators said the $160 Monthly Enhanced Oncology Services (MEOS) payments they will receive for each patient enrolled are intended to contribute to better coordination of care and will come in handy for covering expenses related to implementing the OCM. However, MEOS payments do bring their own set of problems, such as how to track patient chemotherapy treatments accurately so that administrators will know when their practice becomes eligible for these payments. Just as crucial is understanding the events that may trigger discontinuation of eligibility and the need to reverse prior claims for the monthly payments, Russo said. “There’s a number of technical challenges—a lot related to data and information exchange—that we’re trying to get prepared for as quickly as possible.”

Wentworth said the MEOS payments will cover the costs of her job and that of a quality nurse hired for the OCM implementation. But the additional expenses likely will not stop there. In Russo’s case, the Dallas-Fort Worth practice has put nurse navigators and nurse case-management staff in place, and it has had to invest in clinical pathway systems, triage pathway systems, and patient portal systems. Future technological investments are anticipated to simplify the way clinical and quality metrics are reported, Russo said. He’s not certain that the MEOS payments or other compensation offered under the OCM will cover those costs.

Kienert said that it’s still unclear how overall costs are going to be reduced under the model or how practice performance is going to be evaluated against the baseline clinical information that CMS has requested. “We are going to be using a lot of enhanced oncology services, and for the most part, our practice already has done this because we consider it just a part of good patient care.

But some practices presumably are going to be adding resources and then adding cost to their structures, so where exactly are the savings going to be coming from?”

It’s unclear how easy it will be for practices to come out ahead financially. For that reason, it’s important that CMS offered an “upside-only” track for the first three performance periods so that practices can get a sense of whether they can make the OCM work for them, said Kelly Price, vice president and chief of healthcare data analytics at DataGen, a New York-based company that is consulting with oncology practices on OCM implementation. “We would have liked to see that go even further, perhaps.”

Investment Expenses vs OCM Revenues

Much also depends on the volume of patients and particular disease states that practices see, Price said. Prostate cancer cases are typically plentiful and those revenues are predictable; however, for scarcer brain or neuroendocrine cancers, a very costly case may upset the revenue flow. “You have to figure out whether it is something that you can change,” Price said. “Does it have anything to do with a strategy that you put in place or was it a fluke? The smaller your practice, the more monitoring you are going to have to do in order to absorb those things that are beyond your control.”Whether or not practices make or lose money through the OCM will depend on such factors as the “significant” amount of investment many will have to make to effectively comply with the requirements of the model, Price said. “Our impression right now is that a lot of practices are going to get into this for the experience, and that should be very much their attitude.” The MEOS payment will help them to staff up and create the care coordination mechanisms that CMS wants, she said. And “if they don’t lose money, that will be a good thing, because they will learn a lot about the way these programs are going to be constructed and what the new things are that they are going to have to learn going forward.”

One thing CMS still needs to define is how the proposed change in the formula for covering Medicare Part B drugs—the average sales price (ASP) plus 6%—will affect practices enrolled in the OCM, whose original payment formula was based on no change in the Part B payment scheme. Russo said, “We are struggling, as many practices are, to buy drugs even at the current rate—never mind the cost of storage, inventory, and dispensing. I’m hopeful that if they decide to move forward in any way with the ASP ‘experiment,’ that it truly is voluntary and not something that’s applied to the practices that are in the OCM, because we can’t experiment with drug pricing at the same time we’re experimenting with the overall value-based approach.”

Some of the pieces of the OCM were still under assembly right up to the time of the general announcement of the launch. Clinical metrics required by CMS were not fully identified by the agency until early June, and close to the inauguration date, CMS still had not opened the portal to the promised online data registry.

One thing Kienert would like to know is whether CMS is going to help with the promotion of the OCM so that patients are not blindsided when their oncologists tell them about the program and how it’s going to influence the course of their treatment. “I’ve not seen any announcements yet from CMS toward their patients saying, ‘Hey, here’s this great oncology service that we’ve created for you with your payer or your provider. Ask them if you can sign up and be a part of this!’ I’ve seen no advertising of this whatsoever.”

Multiple Payment Formulas Add Complexity

The difficulty is that, without government promotion, providers are going to have to sell the program to patients. If that’s not successful, patients may not want to participate, and there’s a chance that providers won’t want to continue if the OCM significantly misfires in that or other ways, Kienert said. “If it’s revealed within the first year that there really is no picture or path toward patient care—that it’s all about saving money (for CMS)—I think this is going to be a lot like the pioneer ACO (accountable care organization) experiment, and you’ll see a lot of quality practices dropping out, in frustration.”A feature that sets the OCM apart from other physician value models from CMS is that practices will have to track total costs for whatever happens during the 6-month episodes of care. What will make that particularly difficult is understanding the different ways that the various parties involved in patient care receive their compensation, Price said. “Acute hospitals get paid on a per discharge basis, compared with a skilled nursing facility which gets paid a per diem. Long-term hospitals get paid quite differently. Oncologists have enough challenges understanding the nuances in the way they themselves get paid,” Price said.

Figure: Medicare Average Episode Payment by Primary Cancer Type

Source: DataGen

In addition, CMS has created a broad field of measures by which it determines how well a practice is meeting performance targets. “CMS is setting up a whole regression model that brings in factors like the type of cancer, the patient’s age, the numbers and types of comorbidities, the numbers of times that the patient has been treated for cancer previously, how many different types of cancer they have—and that is just a few of them,” Price said. DataGen expects to be working with practices to help them understand how targets are constructed; however, its bigger focus is going to be on helping practices to understand how the care coordination element of the OCM is supposed to occur.

Although CMS has been accused of holding back on information and issuing guidance that is hard to decipher, Price said the agency has been surprising in its readiness to reconsider episodic payment policy based on feedback from the physician and analytical community: “So far, CMS has tried to be responsive, and they have gone back and changed decisions they made that we never imagined they would change their mind about.”

Despite the unknowns, some practices do feel a sense of confidence, going into this, that things will work out. “I don’t think we anticipate making boatloads of money, but I don’t think we’re concerned about losing money either,” Wentworth said. “For the most part, people are willing to embrace what needs to happen. The ultimate goal is to provide even more superior care for our patients. Staff members get on board once they see that’s the goal.”