Currently Viewing:
Currently Reading
Dr Roger Brito Discusses Practitioners Taking on 2-Sided Risk
February 12, 2018
Dr Peter Aran Discusses Year 1 Feedback on OCM
February 05, 2018
Dr Roger Brito on When Providers Should Be Involved in Reimbursement Model Development
January 31, 2018
Dr Mark Fendrick: How Expensive Therapies Fit Into VBID for Oncology
January 29, 2018
Bo Gamble Explains How COA Helps Practices Prepare for OCM
January 27, 2018
Dr Peter Aran on What Oncologists Implementing OCM Can Learn From Existing Models
January 24, 2018
Dr Roger Brito Discusses Implementing Alternative Payment Models and Its Challenges
January 20, 2018
Terrill Jordan Discusses the Process of Customizing an EMR to Adapt to OCM
January 19, 2018
Dr Mark Fendrick: Setting Cost-Sharing Based on Value, Not Price, in Cancer Care
January 18, 2018
David Merrill and John Robinson Discuss Barriers to APMs, Factors of Interest
January 15, 2018
Dr Jeff Patton Discusses Preparing for OCM, Seeing Improved Outcomes and Savings
January 12, 2018
Dr Peter Aran on Involving Providers in Development Process of New Reimbursement Models
January 11, 2018
Sarah Cevallos on Her Advice for Practices Looking to Participate in OCM
January 10, 2018
Dr Roger Brito: What Patients Should Know About Alternative Payment Models, OCM
January 09, 2018
Dr Mark Fendrick on Indication-Based Drug Pricing in Cancer Care
January 07, 2018
Bo Gamble on COA's Role in 2018
January 05, 2018
Judy Berger on What Southwest Airlines Is Doing in Oncology
January 04, 2018
Terrill Jordan Discusses Making Refinements in Year 2 of OCM
January 03, 2018
Sarah Cevallos: Physicians Need More Data to Determine if 2-Sided Risk is Appropriate
December 26, 2017

The Commercial Payer OCM Experience: Year 1

Surabhi Dangi-Garimella, PhD
Representatives from 3 payers who partnered with providers on the Oncology Care Model (OCM) took the stage at Community Oncology Alliance (COA)’s Payer Exchange Summit on Oncology Payment Reform to outline their experience with OCM and how it has differed from other care models.
When the Center for Medicare & Medicaid Innovation (CMMI) floated the idea of the Oncology Care Model (OCM) in 2016, it allowed commercial payers the option of participating in this pilot reimbursement and care delivery model. Multipayer participation was an added incentive for provider practices to consider pilot enrollment—17 payers signed up to participate.

At the Community Oncology Alliance (COA)’s Payer Exchange Summit on Oncology Payment Reform, held October 23-24, in Tysons Corner, Virginia, representatives from 3 commercial payer organizations that volunteered to follow CMMI’s lead to partner with providers on OCM took the stage. Panelists Peter Aran, MD, Blue Cross Blue Shield of Oklahoma (BCBSOK); Rene Frick, Blue Cross Blue Shield of South Carolina (BCBSSC); and Liz McCormick, Priority Health, took the stage to speak with COA’s Bo Gamble.

First, Gamble asked the panelists to provide an overview of their primary focus with OCM.

Frick said that BCBSSC has placed emphasis on monthly care management, shared savings, and upside-only risk in the first year. “We are focused on only the first 3 claims-based OCM measures,” she said, which they will analyze for the practices. In addition, there’s regular communication with the practices, in the form of quarterly face-to-face meetings, for data review. She also said that with this pilot, BCBSSC is focused on only 3 cancer types.

BCBSOK is still working out details, but will cover between 4 to 6 cancer types, Aran told the audience. In an effort to curb reporting requirements on providers, its focus is on 5 quality measures, which will piggy-back on OCM measures.

“We want to make the data reporting as less-burdensome for the practices as possible,” he said.

Aran cited the experience with the patient-centered medical home model, which he described as “a concept that never took off because early adopters did not have the money to build the infrastructure to bring about required changes.” He explained that CMS realized the need to infuse this money upfront so practices could implement necessary changes, such as care navigators or changes with the workflow.

McCormick pointed out the importance of the Monthly Enhanced Oncology Service payment, adding that Priorty Health also is limiting physician reporting to 3 quality metrics, in addition to a depression screening measure and the 13-point Institute of Medicine Care Management Plan.

Highlighting the difference in the scope of the different programs that Priority Health is participating in, McCormick said, “We are a part of CPC [Comprehensive Primary Care]. In the oncology space, we have 5 practices with about 2300 members; CPC+ includes 40 practices with 250,000 members.”

She added that they have restricted shared savings only for practices with 200 or more patients, which means only 1 of their existing provider groups qualifies. “The focus is on in-patient utilization and ED [emergency department] visits.”

Comparing their participation in the Oncology Medical Home, prior to OCM, McCormick said that a big difference has been data mining. “We’d like to have a dedicated data analyst to bring more story-telling to our health plan,” she said, adding that understanding the key impact of the reimbursement model on the plan is important.

Aran said that while collaboration is key, transformation is equally important. He explained that the clinical transformation is not a stand-alone; payers, the pharmaceutical industry, and technology platform vendors are undergoing transformation, as well. “Keep coming back to us even if we seem uncooperative, with programs that make sense, and we will be cooperative,” Aran added.

A major point of contention within OCM has been the discussion around sharing downside risk between payers and providers.

Aran said that a majority of physicians were trained to define risk only in clinical terms, meaning the clinical risk that patients face due to their disease and treatment. “For physicians, it’s hard to think of this risk in terms of business. However, we, as payers, want more buy-in from physicians,” he added.

Priority Health does not risk adjust. “We have contractual addendums, and there are some 2-sided risks in these contracts, but not in the context of OCM,” McCormick said.

With BCBSSC, 2-sided risk falls under the accountable care organization (ACO) program, “OCM practices that are within those ACOs will eventually migrate to 2-sided risk,” she said, adding that only 2 or 3 of their practices that are comfortable with the 2-sided risk would be migrating over.

Aran reminded the audience that the center of the universe needs to be the patient, patients’ families, and lay caregivers. “Come with a plan for care delivery reform, not just bending the cost curve,” he said.

Frick agreed, adding that cost reduction should not mean deficit of quality. “Quality deficit means physicians would lose their part of the shared savings … and we will revisit the model to look for ways to improve.”

Copyright AJMC 2006-2018 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up

Sign In

Not a member? Sign up now!