Can Cancer Care Lead the Way Toward a Value-Based Future?

December 16, 2019

A senior vice president of Archway Health discusses challenges and opportunities of the proposed Oncology Care First model.

The 2019 Medicare Trustees report forecasts insolvency of the Hospital Insurance Trust Fund in 2026, sooner than prior projections.1 A significant contributor to this unsustainable healthcare cost curve for Medicare beneficiaries is cancer-related spending.2 To address this challenge, Medicare is engaging oncologists through new, value-based programs to identify ways to reduce inefficiency and unwarranted variation in spending.

On November 1, 2019, CMS released an informal request for information (RFI) on Oncology Care First (OCF), the highly anticipated successor to the current Oncology Care Model (OCM), which sunsets in 2021. The RFI, which solicits feedback through the extended deadline of December 13, 2019, is an important step in the development of successful models with robust engagement.3

OCF is built on the same framework as other recently announced Medicare “First” models, including Primary Care First4 and Kidney Care First.5 These models off er prospective payments for providing enhanced care services to an aligned patient population and hold provider participants accountable for quality and cost through retrospective performance-based payments (PBPs). The OCF RFI retains many of the favorable facets of the OCM program, including its voluntary status, the opportunity for oncologists to earn additional revenue by reducing expenditures for 6-month episodes of care for Medicare benefi ciaries undergoing chemotherapy, and its qualifi cation as an advanced alternative payment model (APM) under the Quality Payment Program, created by the 2015 Medicare Access and CHIP Reauthorization Act (MACRA).6

The second-generation oncology bundled payment model also strives to improve key aspects of the original program that unintentionally created disincentives for providers. One notable change is a potential revision to how CMS adjusts for new, high-cost drugs. In OCM, one of the only Medicare risk models holding participants accountable for Part D drug expenditures, the novel therapies adjustment is applied at the participant level across all cancer types in aggregate. Because novel therapies are not consistently or uniformly available among diff erent cancer types, the single novel therapy adjustment has created advantages and disadvantages for OCM participants at the practice level because of variation in the mix of cancer types among peer practices and within a singular practice over time. CMS’ consideration in OCF to apply the novel therapy adjustment separately for each cancer type would improve this misalignment. Similarly, a trend factor applied separately by cancer type would remove unfair rewards or penalties that result from variation in patient mix, both internally over time and compared with other groups.

Archway Health’s analysis of 20 OCM practices suggests that to successfully use cancer-specifi c trend factors and novel therapies adjustments, covariates in the model need to be better calibrated. For example, attributes such as radiation therapy or lung cancer are too strongly correlated with PBPs instead of price, pointing to a fl aw in the OCM model. We expect that running a separate regression for each cancer type, similar to how CMS runs a separate regression for each episode of care in the Bundled Payment for Care Improvement (BPCI) Advanced program, will better calibrate covariates.

In OCF, CMS also proposes to improve the alignment methodology for the prospective monthly management payments. In OCM, Monthly Enhanced Oncology Services payments are not available for patients receiving only hormonal therapy when no evaluation and management visit occurs within the 6-month episode period, which led to attribution-related frustration among participants early in the model. In OCF, aligned benefi ciaries covered in the Monthly Population Payments (MPPs) include patients undergoing hormonal therapy only, as well as those under active surveillance or survivors of cancer undergoing care management from their oncologist.

CMS is also changing its approach to getting providers to take risk in OCF. The potential model would have 3 risk tracks that allow providers to pick their pace of assuming risk. Two of these tracks would force downside risk onto current OCM participants immediately, and the third would allow new providers to stay in an upside-only arrangement for 2 performance periods. This contrasts with OCM, in which participants originally could stay in the upside-only arrangement indefi nitely. After the program launched, CMS amended the program and required practices to earn a PBP to stay in the upside-only track. In December 2019, OCM practices that have yet to earn a PBP will be required to switch to the 2-sided risk track or be forced to drop from the program. The OCF RFI indicates that CMS is pushing providers

toward assuming downside risk and also recognizing that some organizations need to get their bearings fi rst in a new program before being held accountable.

Although the OCF RFI incorporates learnings from OCM, it does not seem to take into account the social determinants of health (SDOH), a critical consideration for any care management model and today’s healthcare environment. Social determinants, including access to transportation and healthcare services, aff ect a wide range of health outcomes and risks.7 As an example, oncologists treating patients who live in rural areas may face greater barriers to having patients attend visits and appointments than providers treating patients in areas with more transportation options and less burdensome commutes. Greater consideration for SDOH should be a goal of the OCF RFI process.

The OCF RFI comes on the heels of another major alternative payment policy proposal aiming to improve the value of care received by Medicare benefi ciaries being treated for cancer. In contrast to the voluntary OCF program, the proposed Radiation Oncology (RO) model, announced in July 2019, would be mandatory and affect payment for 40% of the radiation therapy volume provided to Medicare benefi ciaries nationwide, if finalized.8 The model proposes a fixed prospective payment, which includes both professional and technical components, that would vary based on 17 cancer types. Early analysis suggests that this model may incentivize more effi cient treatment schedules, and the final rule is expected in late 2019 or early 2020.

CMS’ goals of reducing care costs and improving care quality are evident through the proposed OCF and RO models. For maximum provider engagement in both oncology payment models, it is imperative that CMS’ payment models continue to make adjustments that do not penalize historically effi cient providers and create value-based innovators across the continuum of care. As providers consider their participation in these programs, they should be aware that frequent and robust data and appropriate quality measurement are critical pieces of a successful program. Additionally, we at Archway encourage providers considering the models to engage with CMS during the comment periods to help the agency build models that align incentives with high-quality patient care.Author Information

Keely Macmillan, MPH, is senior vice president of Policy and Solutions Management at Archway Health. A recognized expert in alternative payment models, she has more than 12 years of healthcare experience in guiding specialty providers to success in accountable care organizations (ACOs), bundled payments, value-based purchasing, and MACRA’s Quality Payment Program.

About Archway Health

Archway Health works with providers and employers to design and execute care and risk management initiatives that improve care and reduce costs. Archway is currently working with leading healthcare providers participating in risk-based contracts including bundled payment programs under the Center for Medicare and Medicaid Innovation such as BPCI Advanced, OCM, and the Comprehensive Care for Joint Replacement model. Archway also works with Medicare and commercial ACOs, self-insured employers, and commercial payers. To support these programs, Archway collaborates with organizations to analyze their opportunities and risks and deploys a comprehensive platform of analytics, patient tracking tools, Value-Based Risk Protection stop-loss programs, and advisory services.References

1. Fact sheet: 2019 Social Security and Medicare trust fund reports [press release]. Washington, DC: US Department of the Treasury; April 22, 2019. home.treasury.gov/news/press-releases/sm665. Accessed November 20, 2019.

2. Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010-2020 [erratum in J Natl Cancer Inst. 2011;103(8):699].J Natl Cancer Inst. 2011;103(2):117-128. doi: 10.1093/jnci/djq495.

3. Innovation Center. Public listening session: informal RFI on Oncology Care First model. CMS website. innovation.cms.gov/resources/oncology-listening-session.html. Updated November 14, 2019. Accessed November 20, 2019.

4. Innovation Center. Primary Care First options. CMS website. innovation.cms.gov/initiatives/primary-care-first-model-options/. Updated November 19, 2019. Accessed November 20, 2019.

5. Innovation Center. Kidney Care Choices. CMS website. innovation.cms.gov/initiatives/kidney-care-choices-kcc-model. Updated November 19, 2019. Accessed November 20, 2019.

6. Advanced Alternative Payment Models (APMs). Quality Payment Program website. qpp.cms.gov/apms/advanced-apms. Accessed November 20, 2019.

7. Office of Disease Prevention and Health Promotion. Social determinants of health. Healthypeople.gov website. healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health. Updated November 21, 2019. Accessed November 20, 2019.

8. Innovation Center. Radiation Oncology Model. CMS website. innovation.cms.gov/initiatives/radiation-oncology-model/. Updated August 7, 2019. Accessed November 20, 2091.