COA Urges Delay in Downside Risk Deadline for OCM

Outlining a set of issues that need to be addressed under the Oncology Care Model (OCM), the Community Oncology Alliance (COA) is urging the Center for Medicare & Medicaid Innovation to delay the October 2019 deadline for practices to transition to 2-sided risk under the model.

The Community Oncology Alliance (COA) has sent a letter to CMS’ Center for Medicare & Medicaid Innovation (CMMI) urging a delay in the October 2019 deadline for practices participating in the Oncology Care Model (OCM) that have not yet achieved shared savings payments to make a decision on 2-sided risk.

Instead, COA is recommending a deadline of April 2020 in order to give practices a third set of reconciliation data, as well as results postimplementation of the updated risk adjusters for breast, prostate, and bladder cancer.

“Making the decision on whether to accept downside risk based on only 2 sets of reconciliation results/data after these key corrections to the methodology were made exposes practices to significant uncertainty rather than quantifiable risk,” states the letter to Adam Boehler, deputy administrator for innovation and quality and director of CMMI.

A recent report from Avalere Health estimated that approximately 70% of OCM practices would owe payments if they were to transition to 2-sided risk.

According to COA, pushing back the deadline to allow for additional results and time to decide on whether to assume downside risk will allow practices to gain key insight into their performance and incorporate risk in a more feasible pathway. It will also keep practices in the model and allow them additional flexibility necessary to evaluate the methodology changes and impact on their practice.

Results from performance period (PP) 3 revealed that just 30% of practices achieved shared savings, which was unchanged from PP2; however, the practices that achieved shared savings differed by performance period. The February 2019 reconciliation also caused practices to experience regressions in their PP2 true-up results resulting in a significant number of practices losing their shared savings.

The majority of practices are unable to determine why they’re doing well or why they’re not doing well when they get their results, explained Bo Gamble, director of strategic practice initiatives at COA, in an interview with The American Journal of Managed Care®, highlighting the need for clarity within performance reports. The complexity of the reports only adds to the frustration of the year-long lag in PP results, said Gamble.

“You can’t change behavior that’s a year old, and therefore, you’re always chasing yourself trying to figure out how to improve,” he said. “That’s what’s frustrating for people. They want to improve, but they want to know, ‘what did I do last month that I can address this month?’”

A solution to this, according to Gamble, could come from tentative information offered to practices on a monthly basis rather quarterly. Practices should also be able to access a practice model where they can plug in their own data and determine how they’re going to do in order to help them understand how their decisions today can impact their model in the future, he said.

In addition to addressing the lag time, there are 3 other areas that COA urged CMMI to address: price prediction, risk adjustment, and attribution and monthly enhanced oncology services payment recoupment.

“Applying price adjustments at the level of the practice, rather than the episode, leads to underpricing for practices that deviate from average national distributions; eg, of population-level characteristics of cancer types,” states the letter.

Other recommendations put forward by COA to address these challenges include:

  • Adjustments for emergent therapies should occur at the episode level, based on which drugs are actually prescribed to the patient, using staging data to determine whether the episode is eligible or ineligible.
  • CMMI should improve pricing for outlier patients so that practices are not penalized, or significantly over-targeted, due to few outlier episodes.
  • Adding surgeries related to all cancer types to the surgery list so that if patients have surgery for any type of cancer, they will have an increased target price reflecting the increased complexity of their cancer episode.
  • Practices should be notified as quickly as possible after an episode is triggered so that patients can be monitored and their care can be managed.

If practices do decide to take on 2-sided risk, there’s also the question of what happens when the 5-year demonstration project ends, explained Gamble, who added that CMMI has not given an indication of what’s to come once the project come to a close. When assuming risk under the OCM, practices are exempt from the Merit-based Incentive Payment System (MIPS). If OCM does not continue after the 5 years, practices are suddenly thrust into MIPS—a completely different program.

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