CMS' Innovation Leader Touts Value of Physician Feedback

October 30, 2019

The Oncology Care Model is a leading innovation in the move from fee-for-service to value-based reimbursement in large part because CMS has made adjustments based on physician feedback, according to an agency official who addressed the Community Oncology Alliance Payer Exchange Summit.

“Robust” feedback from physicians has moved CMS’ Oncology Care Model (OCM) to the forefront of innovation, as the agency moves from fee-for-service to value-based reimbursement, according to a key advisor on the front lines of the shift.

Anand Shah, MD, a radiation oncologist who is senior medical advisor for Innovation at CMS, shared his appreciation for the role that front-line oncologists have played in the success of the OCM during Tuesday’s conversation with Ted Okon, MBA, executive director of the Community Oncology Alliance, during the Payer Exchange Summit in Tyson’s Corner, Virginia.

“A model is an assumption, so it’s never 100% perfect,” said Shah, who started out in the Center for Medicare and Medicaid Innovation (CMMI), the CMS entity that develops alternative payment models called for under the 2015 Medicare Access and CHIP Reauthorization Act (MACRA).

“It is government, so oftentimes change is slow,” Shah said. But he said CMMI worked to incorporate the “physician voice,” while balancing the need to conduct valid tests of different models. Okon praised their efforts, adding, “Everyone knows I can be a little critical at times.”

The result, Okon said, is that OCM has done much more than change reimbursement. Leaders of community practices have described fundamental changes in the way care is delivered—from greater focus on survivorship to stronger communication between physicians and patients to fewer hospitalizations and better delivery of palliative care.

In some ways, Okon said, “it can’t be quantified, but it is very real.”

The multipayer OCM has reached a crossroads, as the 175 practices taking part must decide by December if they want to move to 2-sided risk for the remaining time in the program, which ends in 2021. CMS will convene a “listening call” on November 4 to plan for the successor to the OCM. As reported in Evidence-Based Oncologyin June, feedback led to changes that appear to have made it easier for practices to move forward with 2-sided risk, based on Monday’s presentations during the first day of the Payer Exchange Summit.

The original decision point on 2-sided risk was this month; Okon gently pressed Shah for an additional extension to April to give practices more time to weigh the unknowns. Shah didn’t commit, but noted that the OCM is a partnership between CMS and the practices. “It is an unknown for us as well,” he said.

Okon and Shah also discussed the current debate around the radiation oncology model, which has been proposed as a mandatory model, to the dismay of leaders of the American Society of Radiation Oncologists. Shah said this was a good example where there has been “robust feedback.”

Reimbursement structures in radiation oncology differ from those in medical oncology, Shah noted, because of the capital investment that is required. So, the question has arisen, “How do I deal with my capital in this model?”

Okon noted that, unlike medical oncology, until this proposal, radiation oncology had been “insulated” from payment reform.

Areas for the Future

Shah expects to see more progress on “multipayer alignment,” so that practices are not trying to juggle multiple quality measures and requirements for different patients who walk through the door. In 5 to 10 years, he hopes to see “one set of incentives with no unintended consequences.”

Okon asked about the 2 big cost challenges in oncology: how to handle new therapies, especially gene-based therapies, and how to deal with “the sickest of the sick,” who drive up costs not just in the OCM but across Medicare.

“I don’t think any legislation can address that,” he said.

Shah said this is an important issue. “When we refer to the sickest of the sick, we are working very actively both in primary care and in Medicare Advantage to see how we can provide these patients with the most intensive wraparound services,” he said.

“How do we get these folks the care they need, to keep them out of the emergency room?” Shah asked.

Okon said that addressing this group’s needs is critical, not just from a cost perspective but also to improve their quality of life. “When you talk about innovation, that’s something we really have to look at.”