COVID-19 Adds New Wrinkle in Shift to 2-Sided Risk in Oncology Care

April 23, 2020

Oncology practices could use more time to become accustomed to 2-sided risk even without a global pandemic, but the current crisis makes the need more urgent, say payment reform leaders at the Community Oncology Alliance virtual conference.

Asking federal officials to give oncology practices pursuing alternative payment models (APMs) more time before shifting to 2-sided risk was already a worthy cause. But the global pandemic of coronavirus disease 2019 (COVID-19) gives this request more urgency, according to the co-chairs of payment reform committee of the Community Oncology Alliance (COA), which held a panel discussion on the first day of the group’s virtual meeting.

Moderated by Bo Gamble, COA’s director of Strategic Practice Initiatives, the discussion with co-chairs Kashyap Patel, MD, chief executive officer of Carolina Blood & Cancer Care Associates, and Lalan Wilfong, MD, executive vice president for Value Based Care & Quality Programs at Texas Oncology, showed that several practices taking part in the Oncology Care Model (OCM), advanced by the Center for Medicare and Medicaid Innovation (CMMI), were willing to commit to 2-sided risk despite their struggles thus far to achieve bonus payments under the model.

COA surveyed 175 practices, receiving 68 responses, and learned that 32% of practices planned to pursue 2-sided risk despite not having received a performance-based payment in the first 4 evaluation periods. “That was really amazing to us,” Gamble said. For the practices, however, value-based payment represents the future, and they vowed to keep trying.

Patel, one of the few practice leaders who received bonus payment in each of the first 4 periods, explained how give-and-take between COA practices enrolled in the OCM has led to critical adjustments that have kept the cause of payment reform going. In particular, collaboration led to changes in calculations for stop loss that would have caused widespread abandonment of the OCM. But that collaboration is crucial now, because under an original schedule, the OCM was set to end and a new model, Oncology Care First (OCF), would take effect instead starting next year.

And then came COVID-19, which changed everything. For starters, the final look of OCF is on hold, Patel said, because CMS is busy dealing with the fallout of the pandemic. “We were expecting the model to come out by spring,” he said, but with COVID-19, “Everything has been postponed.”

Even before the current crisis, practices were asking for more time to get a feel for 2-sided risk—because oncologists are at widely varied states of readiness for such a change. Add a pandemic that has forced practices to conduct visits via telemedicine and puts patients with cancer at higher risk of hospitalization because they are immunocompromised, and all bets are off.

As Wilfong explained, the OCF features a dramatic change from a model built on a fee-for-service framework to a monthly prospective fee. “That’s a huge change, and practices need to fully understand what that looks like,” he said, so that staffing and operations can be aligned accordingly. Transparency is needed across the board, Wilfong said.

Models must reflect the differences among practices in the types of cancers treated, he said. “We have to make sure we’re adjusting for the patients in front of us,” Wilfong said. Multiple myeloma, for example, is an area with dramatic treatment advances, so that must be taking into account.

Gamble later explained the concept of “tiered ASP,” in which the percentage of average sales price (ASP) that practices receive for administering drugs would be on a sliding scale, with higher percentages for cheaper, generic drugs and much smaller ones for newer, 6-figure drugs. The idea, Gamble said, is to end the myth that oncologists prescribe based on what they will be paid. Also, he said, “it brings some great competition in the market to bring prices down.”

A year ago, COA was poised to bring a revised version of the OCM, called OCM 2.0, before a federal entity called the Physician-Focused Payment Model Technical Advisory Committee (PTAC), as a way to address the weaknesses seen in the original OCM, especially issues with the way it pays for drugs. Today, however, with the arrival of the proposed OCF, the group has reimagined OCM 2.0 as tiered model that includes commercial practices, with entry points for all types of practices—from those experienced with taking on risk to those just getting started.

And Wilfong said going forward, CMMI must reach a point of building models that recognize strong, ongoing performance. “Once you trim the fat, there’s a point where there’s no more fat to trim,” he said. “At some point, we had to really think about rewarding those practices for doing the right thing.…And then we have to also, especially now, think about minimizing our beneficiary costs.”