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The Commercial Payer OCM Experience: Year 1
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AJMC Staff

The Commercial Payer OCM Experience: Year 1

Surabhi Dangi-Garimella, PhD
Coverage from the Community Oncology Alliance (COA)’s Payer Exchange Summit on Oncology Payment Reform, held October 23-24 in Tysons Corner, Virginia.
IN 2016, 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. Seventeen 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 the 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 the 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 focusing on 3 cancer types.

BCBSOK is still working out details, but will cover between 4 and 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 up front 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 [emergency department] visits.”

Comparing their participation in the Oncology Medical Home, prior to the 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 the 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 the 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.”
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