COA Close to Filing OCM 2.0 for Federal Review

April 5, 2019

The first day of the 2019 Community Oncology Conference, the major annual meeting of the Community Oncology Alliance (COA), featured an update on its effort to find alternatives to CMS' Oncology Care Model.

After a year in development, the Community Oncology Alliance (COA) will file its alternative to CMS’ Oncology Care Model (OCM) later this month with the Physician-Focused Payment Model Technical Advisory Committee (PTAC), a federal agency that reviews models for possible use by Medicare.

Bo Gamble, COA’s director of strategic practice initiatives, announced Thursday that the plan known as “OCM 2.0” was near completion during a panel discussion on the first day of the 2019 Community Oncology Conference, taking place in Orlando, Florida. Gamble appeared with Basit Chaudhry, MD, PhD, founder and Chief Executive Officer of Tuple Health; Kavita Patel, MD, MS, a former Obama administration policy official also with Tuple Health; and Bruce Gould, MD, medical director of Northwest Georgia Oncology Centers, chair of COA’s committee on oncology payment reform.

Gamble, Patel, and Gould previously reported on OCM 2.0 last fall during COA’s Payer Exchange Summit, describing it as a template that could be used by Medicare, commercial payers, and even self-insured employers, by addressing many of the frustrations that community oncology practices see with the current incarnation of OCM. These include issues with patient attribution, too many reporting burdens, methodological flaws in the rating of geography and quality measures, and a reimbursement scheme that has not kept pace with the soaring cost of oncology therapies. Most of all, as COA expressed a year ago, a lack of transparency makes it difficult to participants to understand their results.

Thursday’s session, “From OCM 1.0 to 2.0: Two Paths to Payment Reform,” offered an additional update on the complexities of CMS’ signature 5-year alternative payment model (APM), which covers 176 practices and is scheduled to run through June 2021. So far, no plan for an OCM extension or successor has been announced, and Gamble said after the session that practices need information on what will come next.

Chaudhry explained that OCM has reached a crossroads. Early on in the model, practices often focused on implementing administrative requirements. As a result, more substantive clinical transformation efforts frequently started later. Results from performance period 3, which came out a few weeks ago, did not show progressive improvement overall. The share of practices that received a performance-based payment in performance period 3 was the same as the share of practices in performance period 2. The percent of practices achieving shared savings didn’t increase.

With OCM practices facing a deadline to decide if they will take on 2-sided risk, he said, “both of these trends are quite concerning.”

Gamble and Gould said that there are many things about the OCM that have improved cancer care, but the way the model handles drug pricing means that practices that are doing everything right can still miss out on shared savings.

“I’m a big believer in personal responsibility,” Gould said. Oncology practices should be good stewards of healthcare dollars; they must provide team-based care that helps patients navigate their way through cancer treatment, including “closing the loop” after a consultation.

But, he said, the OCM uses pricing models that were developed with claims data from 2012 to 2015, before the explosion of immuno-oncology drugs. Not only do newer drugs cost more per month, but patients take today’s targeted therapies for longer periods of time. Even with OCM changes like the novel therapy adjustment and the trend factor, Gould said, “[the] pricing model is not relevant with what we do today.”

The complexity of the model also strains practices, he said, estimating that a practice with 1000 patients will need to report 8000 to 15,000 data elements, many of them by hand.

When an audience member noted that the OCM doesn’t account for off-label uses that appear in the National Comprehensive Cancer Network guidelines, Patel said it would be unthinkable for a government agency like the Center for Medicare and Medicaid Innovation (CMMI) to look beyond FDA-approved uses in building a reimbursement model. It’s just not how the government operates, she said.

Patel said instead of trying to stay ahead of rising drug prices with “complex and wrong adjustment factors,” CMMI would be better off coming up with a set price for what it costs to treat a patient, “and give you something on top of that, so you can survive and thrive.”

“But I’m not in charge of CMS, so it’s easy for me to say that,” she added.

During his presentation, Gamble reviewed the process COA used to develop the proposal that will go to PTAC, which was created to evaluate APMs developed by physicians, in addition to those developed by CMMI. Despite expectations early in the Trump administration that PTAC’s profile would increase, so far CMS has not authorized oncology models blessed by the group to compete with the OCM.

COA decided to work with its member practices, some payers, and pharmaceutical companies to develop OCM 2.0 for the simple reason that the errors and problems it identified were not being fixed quickly, and the escalating costs of oncology drugs in Medicare Part D were not getting enough attention. In short, Gamble said, the alliance asked, “Why is there not a better way to do this?”

As Gould’s committee collected feedback, Gamble said, a key step involved gathering practice leaders responsible for understanding the revenue cycle of the OCM and bringing them together to brainstorm on solutions. Another critical step was meeting directly with leaders of drug companies and asking how COA could forge value-based agreements directly with providers—something that payers typically do with pharmaceutical companies while purposely leaving providers in the dark. “That lack of transparency is impacting the patient and the provider teams,” Gamble said.

“We had a series of close to 12 face-to-face discussions with drug companies,” he said. The tone was, “We see the challenges in your world, you see the challenges in our world.”

OCM 2.0 will not look like other payment models, Gamble said. It will be more of framework based on the best elements seen by other oncology models put forward, including initiatives from the American Society of Clinical Oncology. But Gamble promised it will take on the issue of rising drug costs in ways other models have not.

Meetings with pharmaceutical companies in particular will soon bear fruit, Gamble said. “I believe in a very short while, you’re going to see more value-based scenarios involving providers than you ever have before.”