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Evidence-Based Oncology June 2019
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Institute for Value-Based Medicine
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Institute for Value-Based Medicine

Laura Joszt, Samantha DiGrande, and Wallace Stephens
Coverage from The American Journal of Managed Care's® Institue for Value-Based Medicine® meetings.

Even With Room for Improvement, OCM Practices Agree: They Would Participate Again

As the oncology care model (OCM)1 begins to wind down and CMS and the Center for Medicare & Medicaid Innovation (CMMI) look ahead to a replacement called OCM Plus, now is the perfect time to discuss what will come next in the oncology reimbursement space, according to Blase Polite, MD, associate professor of medicine at the University of Chicago Medicine. 

Polite led a discussion on the state of the OCM and other alternative payment models (APMs) in oncology on April 25, 2019, in Chicago, Illinois, during a session of the Institute for Value-Based Medicine®, an initiative of The American Journal of Managed Care®. He gave the audience and fellow panelists 3 questions to consider throughout the presentations: 
  • How would we grade OCM 1.0? 
  • What has the model done well, and what has it done poorly? 
  • If we had to choose among OCM 1.0, 2-sided risk, or the current fee-for-service model going forward, what would we choose? 
“Why are we talking about all this? Because we have a system that’s not sustainable for our patients,” he said. Already, the average premium for a family of 4—which was $28,166 in 2018—is rising much faster than the median family income, and employees are being asked to pay a higher share of their healthcare costs every year.2 

“This number becomes worse for patients with cancer. [These] patients are at 2.65 times [the] risk of bankruptcy, and that affects mortality. In fact, patients that have bankruptcy and cancer are at a 79% greater risk of mortality,” said Polite.

ASCO’s Payment Model 
After setting the stage for the importance of, and need for, new payment models in oncology, Polite introduced Stephen Grubbs, MD, vice president of clinical affairs at the American Society of Clinical Oncology (ASCO), to present on ASCO’s APM, the Patient- Centered Oncology Payment (PCOP) model.

“Where we are with ASCO is doing a refresh with what’s learned from other episodes…. We’ve had employers involved with us— self-insured employers—because they’re going to drive a lot of this,” Grubbs said. 

Right now, ASCO is looking to revitalize its priorities in terms of its payment model and address problems such as synthesizing care delivery and payment reform, establishing an acceptable provider risk, incorporating lessons learned from the OCM, and others. 

Grubbs explained that ASCO has shifted away from the one-size-fits-all approach on a national level and instead is looking to install a regional model, although that kind of infrastructure is not yet in place. 

“It’s not a secret that the practices in the OCM are among the best in the United States and have the infrastructure in place and ways of doing this that a lot of other places don’t have,” said Grubbs. 

The PCOP model is organized by 3 tiers: Tier 1 is for beginning practices starting the OCM, followed by a 3-year period for the practice to work up to a higher level to tier 2, or monthly payments, until finally the practice can achieve tier 3, or bundled monthly payments. To date, no practices enrolled in the PCOP model have been able to achieve tier 3. 

In order to help transition into this payment model, track 1 has basic targets listed for practices to achieve, including: 
  • Offering education around finances 
  • 24/7 telehealth access 
  • Oncologist leadership/referral relationships 
  • Completeness of clinical data/patient feedback 
  • Basic quality oncology practice initiative safety standards 
  • Use of clinical treatment pathways 
  • Use of certified electronic health record technology 
Importantly, an overarching question when it comes to oncology payment models has been, as Grubbs puts it, “What the heck to do with drugs?” 

“We’re taking the cost of drugs out of your formula for how you’re paid,” said Grubbs. “ASCO’s position has been, and continues to be, that US oncologists should be accountable for using the drugs properly. Administering them to the right patient with the right disease at the right time. If we do that, then we [the practice] shouldn’t be responsible for the cost of the drug.” 

How to incorporate drugs into an oncology payment model has proven difficult, and for this reason, the OCM has thus far left drugs out of the equation. However, whether or not the cost of drugs will be addressed in the next phase of OCM remains to be seen. 

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