While the Oncology Care Model (OCM) is likely not a sustainable mode for oncology care, it will probably inform what payment structure comes next, said Michael Kolodziej, MD, vice president, chief innovation officer, ADVI Health, Inc.
Eventually, practices in the OCM are expected to either leave the pilot or move out of 1-sided risk and into 2-sided risk. Kolodziej would have predicted that no practices would choose to take 2-sided risk, but it seems clear some will. Regardless, he still believes there is “no way” the majority of practices in OCM will move into 2-sided risk. And these are practices that are highly selected and were high performers before joining OCM.
“So, the concept that this model will be rolled out to everybody, and everybody will take 2-sided risk in the model, is, I think, just ridiculous,” Kolodziej said.
He thinks that it is more likely the OCM will help pave the way for more bundled payments in oncology. The model has created a turning point in oncology care, agreed Bryan Loy, MD, physician lead, oncology, laboratory, and personalized medicine, Humana.
Loy said that CMS has created a catalyst in oncology care by initiating the OCM and creating an environment where people realize there’s no turning back and it is time to make fundamental changes to transform how care is delivered.
“We’re very excited the ice has been broken,” he said, although he thinks there are simpler models out there.
What comes next? Kolodziej believes it depends on what happens with a number of other programs and initiatives coming out of Washington, DC, such as the International Pricing Index and the Competitive Acquisition Program. But if neither of those work out, the information gathered from 5 years of the OCM could allow CMS to design clinically meaningful reimbursement models, he suggested.
CMS might just tell practices what they would pay for something like early-stage hormone receptor–positive breast cancer and the practices can take it or leave it. “So, not unlike what they’re doing in radiation right now,” Kolodziej said.
This model hadn’t been possible in medical oncology previously, because medical oncology is too heterogeneous. In comparison, there is a limited number of tools in the toolbox for radiation oncology, he explained.
Now, with the information and data gathered through the OCM, CMS knows more, such as the cost centers for a typical patient or what a reasonable emergency department utilization rate looks like. Plus, CMS has that information for different subsets of patients, including different ages, geographies, and comorbidities.
This next step would not be able to happen for a few years, because some practices will stay in OCM right to the end of the 5-year pilot.
“But while they’re in that year 4/5, [CMS is] going to be finetuning and developing these bundles, I think,” Kolodziej said.