Laura is the editorial director of The American Journal of Managed Care® (AJMC®) and all its brands, including The American Journal of Accountable Care®, Evidence-Based Oncology™, and The Center for Biosimilars®. She has been working on AJMC® since 2014 and has been with AJMC®'s parent company, MJH Life Sciences, since 2011. She has an MA in business and economic reporting from New York University.
Coverage from The American Journal of Managed Care's® Institue for Value-Based Medicine® meetings.
As the oncology care model (OCM)1 begins to wind down and CMS and the Center for Medicare & Medicaid Innovation (CMMI) look ahead to a replacement called OCM Plus, now is the perfect time to discuss what will come next in the oncology reimbursement space, according to Blase Polite, MD, associate professor of medicine at the University of Chicago Medicine.
Polite led a discussion on the state of the OCM and other alternative payment models (APMs) in oncology on April 25, 2019, in Chicago, Illinois, during a session of the Institute for Value-Based Medicine®, an initiative of The American Journal of Managed Care®. He gave the audience and fellow panelists 3 questions to consider throughout the presentations:
“Why are we talking about all this? Because we have a system that’s not sustainable for our patients,” he said. Already, the average premium for a family of 4—which was $28,166 in 2018—is rising much faster than the median family income, and employees are being asked to pay a higher share of their healthcare costs every year.2
“This number becomes worse for patients with cancer. [These] patients are at 2.65 times [the] risk of bankruptcy, and that affects mortality. In fact, patients that have bankruptcy and cancer are at a 79% greater risk of mortality,” said Polite.3
ASCO’s Payment Model
After setting the stage for the importance of, and need for, new payment models in oncology, Polite introduced Stephen Grubbs, MD, vice president of clinical affairs at the American Society of Clinical Oncology (ASCO), to present on ASCO’s APM, the Patient- Centered Oncology Payment (PCOP) model.4
“Where we are with ASCO is doing a refresh with what’s learned from other episodes…. We’ve had employers involved with us— self-insured employers—because they’re going to drive a lot of this,” Grubbs said.
Right now, ASCO is looking to revitalize its priorities in terms of its payment model and address problems such as synthesizing care delivery and payment reform, establishing an acceptable provider risk, incorporating lessons learned from the OCM, and others.
Grubbs explained that ASCO has shifted away from the one-size-fits-all approach on a national level and instead is looking to install a regional model, although that kind of infrastructure is not yet in place.
“It’s not a secret that the practices in the OCM are among the best in the United States and have the infrastructure in place and ways of doing this that a lot of other places don’t have,” said Grubbs.
The PCOP model is organized by 3 tiers: Tier 1 is for beginning practices starting the OCM, followed by a 3-year period for the practice to work up to a higher level to tier 2, or monthly payments, until finally the practice can achieve tier 3, or bundled monthly payments. To date, no practices enrolled in the PCOP model have been able to achieve tier 3.
In order to help transition into this payment model, track 1 has basic targets listed for practices to achieve, including:
Importantly, an overarching question when it comes to oncology payment models has been, as Grubbs puts it, “What the heck to do with drugs?”
“We’re taking the cost of drugs out of your formula for how you’re paid,” said Grubbs. “ASCO’s position has been, and continues to be, that US oncologists should be accountable for using the drugs properly. Administering them to the right patient with the right disease at the right time. If we do that, then we [the practice] shouldn’t be responsible for the cost of the drug.”
How to incorporate drugs into an oncology payment model has proven difficult, and for this reason, the OCM has thus far left drugs out of the equation. However, whether or not the cost of drugs will be addressed in the next phase of OCM remains to be seen.
Should the OCM Change How Episodes of Care are Triggered?
As CMS looks to revamp the OCM, many participants in the current model have suggestions for what to include or change in the new rendition. Jessica Walradt, manager of Managed Care of Government Programs, Value-Based Care, at Northwestern Memorial Healthcare, shared her take on the payment model.
Walradt first explained what she views as the necessary elements for a well-structured APM:
First, Walradt explained, CMS should adjust how episodes are triggered within the OCM. At present, an episode of care begins under the OCM the moment chemotherapy is administered. “On average, we only correctly identify about 80% of our OCM patients. We’re missing that other 20% because of the way episodes are triggered. Right now, we’re capturing patients on maintenance therapy, and because of that, we’re not effectively managing their care,” said Walradt.
Instead, the model should exclude oral chemotherapy drugs and maintenance therapies and instead focus on patients whose care is being actively managed. This would reduce the volume and “reduce a lot of episodes that we’re making money on, but think of the tradeoffs with the goal of the program to do better for the patients you’re managing,” Walradt said.
In terms of what to do with drugs within the payment model, Walradt suggested to either adjust for them or remove them. She presented a graph that showed the average episode payment by stage of disease, further broken out to represent the cost of what the episode comprised, including chemotherapy, emergency department (ED) use, hospice, and other Part D drugs.
Finally, Walradt touched upon the administrative burden of data submission that comes with being part of the OCM.
“We’re spending tons of time submitting all of [these] data to CMS, and it’s very important that they have it, but it’s not sustainable,” said Walradt. “CMS should rely more heavily on the registries that we’re already reporting to, but CMS says that they ‘can’t promote one single registry over another.’ However, if we give up on this idea of using clinical data in this area, then we could say, ‘Let’s stop reporting,’ in general, and instead risk adjust [the] target price without clinical data.”
Notably, Northwestern Memorial Healthcare has not received shared savings under the OCM thus far. Similarly, Mark Walshauser, MD, FACP, oncologist at Cancer Care Specialists of Illinois (CCSI), explained that his practice had also not achieved shared savings under the OCM, although it did see other success.
What Success Can Look Like in the OCM
Prior to enrolling in the OCM, Walshauser’s practice had much of the requirements in place:
Initially, Walshauser recognized that 50% of the cost of an episode of care for his practice under the OCM was the cost of drugs. The next highest expenditure was inpatient admissions to the ED, at 20%, followed by end-of-life care.
In order to address these “low-hanging fruit,” Walshauser’s practice teamed up with New Century Health to develop pillars and action items to address each initiative. In terms of the high cost of drugs per episode, the practice focused on providing treatment using evidence-based pathways, consulting a clinical advisory board prior to beginning treatment with a particularly expensive therapy, and using decision-support tools. This, in turn, helped the practice to use less expensive regimens and more targeted interventions.
To address the high rate of admissions to the ED, the practice employed real-time risk stratification and focused on having nurses triage patients. This led to consistency in patient triage and high-risk targeting. “Our hospital system is servicing 16 hospitals. We’re looking for outliers. If a hospital is admitting 80% of patients that walk into the emergency department, we’re meeting with their administration,” said Walshauser.
Finally, to address the high expense of end-of-life care, Walshauser and his team looked to facilitate more palliative care referrals, educate patients, and instill more provider engagement. This improved the end-of-life transitions in the hospital system as well as the quality of care.
After implementing each of these targeting systems, Walshauser found that since the start of 2017, the median drug cost of practices in the OCM went up 20%; however, CCSI’s spend has only gone up 6%. Specifically, for Medicare Part D drugs, the average spend for OCM practices have gone up 23% while CCSI’s only increased 4%.
Despite this great success and an estimated annual savings to Medicare of nearly $3.5 million, CCSI just missed achieving shared savings. Walshauser noted, “We’re a major player in our hospital referral system. The target price is calculated by hospital regional referral, and we’re the main provider of cancer care. So, if we bring our costs down, it mirrors so that we’re competing against ourselves. We keep saving money, but the target price keeps going down. This is an issue. In a 2-sided risk model, we would have achieved shared savings. Going forward, we need to max out our complexities, and due to the administrative burden of the data required by CMS, we’re probably underreporting and not getting enough credit for things we are doing.”
Finally, the last speaker of the night, Roger Brito, MD, senior medical director at Aetna, offered the payer perspective on APMs.
OCM Needs Updates, but Practices Still Find Value in the Model
Aetna offered its own APM to oncology practices, dubbed the Oncology Medical Home (OMH). Brito describes the system as a “patient-focused way of delivering quality cancer care that reconstructs the fee-for-service model to value-based care.” Value-based care is extremely important to Aetna, Brito explained, as the organization looks for 80% of all of its contracts to be value-based care.
Within this model, payers share data and metrics with providers in a way that allows the providers to increase adherence to clinical pathways and enhances the patient—physician relationship.
“The OMH payment system is based on measured results and quality that allow the right care to be delivered at the right time,” said Brito.
In order to qualify for the model, providers must meet certain criteria, such as having Aetna network support in adding a practice to the OMH program and meeting patient population thresholds. Brito stressed that under this model, Aetna isn’t looking at the cost of drugs, but the utilization of drugs. The model “pursues improved patient outcomes by encouraging pathway alignment and quality care improvement.”
However, one of the greatest benefits of this program, in Brito’s opinion, is the frequent reporting and enhanced communication between the provider and Aetna. “This enhanced communication provides practices with timely, actionable information that they can really put to use,” said Brito.
Although much of the presentations focused on what the OCM could be doing better and what changes each presenter would like to see in the next rendition of the model, when an audience member asked if the panelists would participate in the model again with their current knowledge, the panel answered with a resounding “yes.”
“We have to learn the competencies of how to manage a patient population. With this program, you get to be part of the conversation with Medicare as they’re developing the model. OCM practices and stakeholders have changed the model in real time,” said Walshauser.
Polite concurred and offered his own take: “The data we get back from this program is almost too good. We don’t know what to do with it. We now have claims level data on individual patients, where we can look at every single patient that came in above and below a target and figure out why that happened. If you believe value-based payments are the future, having that understanding and doing that in a fairly low stakes environment, you can’t put a price on that,” said Polite.
Although fee for service has long been the model that determines compensation for physicians, hospitals, and other healthcare services, a transition to value-based care could be the solution to suppress rising healthcare costs, expand access to care, and increase accountability in an attempt to achieve better health-related outcomes.
Healthcare professionals throughout the United States agree that the current payment model is flawed and unsustainable. Efforts to shift toward a value-based care model have gained momentum, but much progress is needed before the transition can be expected to encompass the entire healthcare industry.
“We are very slow to change. We have our routine; we are steeped in safety,” said Shalom Kalnicki, MD, FACRO, during a meeting of The American Journal of Managed Care®’s Institute for Value-Based Medicine®, held April 16, 2019, in White Plains, New York.
“We wanted to create a new economic paradigm in healthcare,” said Kalnicki, the meeting’s moderator. Quality care management, administrative services, and the role of information technology are all areas that are expected to change significantly during the shift to value-based care.
Payers, providers, and consumers constantly seek new ways to combat continually rising healthcare costs. Oncology care has been a crucial area of concern that greatly contributes to the nation’s overall healthcare expenses. Although CMS’ Oncology Care Model (OCM)1 has achieved success in reducing costs, expanding access to care, and increasing the quality of care, further action must be taken in the effort to transition to a value-based system.
However, simply laying down a blueprint isn’t enough. Cohesion is needed among all parties involved in the healthcare system to achieve true change. Presenters from the meeting demonstrated that value-based care has the potential to significantly improve the lives of patients by achieving better health-related outcomes while contributing to lower overall healthcare costs.
“Doing the right thing and complying with it have an incredible financial impact,” Kalnicki stressed.
A New Radiation Oncology Alternative Payment Model
Blair Burnett, senior policy analyst at the Association of Community Cancer Centers (ACCC) in Washington, DC, mentioned that although 70% of providers are involved in some value-based arrangements, the field of radiation oncology has stalled in making strides toward value-based care.
Burnett stressed the need to include radiation oncology in future discussions about value-based care. “It’s always viewed in much more of a passive lens when radiation oncology comes into the picture, even when you’re thinking about the context of how practices are paid, how that payment system works out, and reimbursement,” she said. “Radiation oncology is included in these episodes, but there really was a need for a model to [assimilate] radiation oncology into value-based care.”
A potential radiation oncology alternative payment model (RO-APM) may help steer the field toward value-based care. Burnett said the model would be applicable in both hospital and freestanding settings. It would replace the Medicare physician fee schedule and the hospital outpatient prospective payment system. The potential RO-APM is based on many principles from the American Society for Radiation Oncology (ASTRO’s) 2017 proposal2 and is expected to increase patient access to the best care available. The new model is anticipated to cover 17 disease sites compared with the 5 covered by the ASTRO proposal.3
Whether the new RO-APM will be considered mandatory or voluntary remains in question, but the result could strongly affect public opinion. Burnett said the model is expected to be mandatory.
“If 50% of the population is expected to fall in line with this model, we’re going to hear a lot of outcry, and there would likely be a point when different provider advocacy groups, like ACCC and ASTRO, need to band together to discern the needs of the radiation oncology community and determine whether a mandatory model would be more effective in a transition to value-based care,” Burnett said.
Another goal of the new RO-APM is to set benchmarks for target prices. Burnett remarked on challenges that OCM creators faced while trying to determine prices.
“We’re at the forefront of a lot of decisions that are going to be affecting primary care physicians…, future models in cardiovascular disease, and a lot of other disease states that are plaguing healthcare spending on a national level,” she said.
Burnett said she expects CMS to issue a proposal for the RO-APM in summer 2019. How the model will alleviate the burdens faced by previous models remains critically unanswered. “If we can tackle value-based care from an oncology care standpoint, we can tackle any other field,” she said.
Are Value-Based Care and Patient-Centered Care Compatible?
A patient-centered approach to care could contribute to a reduction in total healthcare costs, suggested Beth Wittmer, RN, OCN, senior manager of care management at the Florida Cancer Specialists and Research Institute (FCS), based in the Sarasota area. The company offered individualized care plans to ensure all patients received optimal medical treatment in addition to emotional support when they needed it most.
“Our care management department is team based, patient centered, and definitely designed to assist the patients, and for me as, a nurse, I see nothing greater than knowing that I can offer value-based care, and it’s not just talked about. It’s something that I’ve always believed in. It encompasses coordination of care, which is needed to manage the many issues related to oncology treatment,” Wittmer said.
FCS proved that community oncology practices have the capability to reduce hospitalizations and emergency department (ED) visits. When patients were admitted to a hospital, the FCS personally called them to verify the reason. The information it gathered helped FCS to implement new preventive measures.
“In just a short amount of time, we were able to reduce patient [ED] visits and hospitalizations by 34%,” Wittmer said. Indeed, FCS’ success was measurable: Its patients also had 17% fewer hospital admissions than those of other similar practices, and ED visits reported by FCS’ patients were 29% less than those of its peers. The practice also developed a nutrition program and made sure its patients stayed hydrated.
Major obstacles that FCS needed to overcome were related to barriers to care. The practice understood that the struggles its patients faced didn’t cease when it closed the doors for the day. As a result, physicians and nurses were placed on call to allow patients to speak with them anytime, day or night.
“If you’re getting after-hours phone calls, a lot of that is emotional support,” Wittmer said. “[Patients are] afraid, and I think they’re willing to call a nurse who’s on call versus the doctor because they don’t want to talk necessarily about how they’re feeling.”
FCS also extended its weekend hours and strived to make sure patient phone calls were never left unanswered. Wittmer said that FCS tries to never leave people on hold or send them to voicemail.
“It’s a culture shift in order to think in a new way. It isn’t easy, but we can’t be in healthcare without it,” Wittmer concluded.
Hot-Spotting to Identify High-Risk Patients
Although Crystal Run Healthcare had some programs in place before the OCM to help it transition to the new way of delivering care, the practice needed to implement a handful of new programs. These included instituting new oncology pathways to reduce variation, hiring a social worker dedicated to oncology patients, and implementing continuous quality improvement efforts, explained Manuel Perry, MD, director of the Oncology Care Model and division leader of hematology/oncology for the Middletown, New York, practice.
Crystal Run also used a method of risk stratification called hot-spotting. Jeffrey Brenner, MD, the founder of the Camden Coalition of Healthcare Providers in New Jersey, initially used the concept in healthcare to collect patient-level data from local hospitals to map out high-cost areas. After Brenner placed outpatient clinics in buildings with higher utilization, hospital ED visits dropped by 40% and costs decreased by 56% in Canada.
Healthcare hot-spotting uses data to reallocate resources to the small number of high-need, high-cost patients that the American healthcare system struggles to care for, Perry said. When these patients have frequent contact with the system, without measurable improvement, they are often given more expensive, invasive, and risky treatments.
“Super utilizers are the patients our standard systems have failed,” Perry said.
After witnessing its inpatient admissions rise steadily, Crystal Run developed a hot-spotting method to identify its super utilizers and used an existing framework to stratify patients prospectively in order to offer services. “We wanted to increase the frequency of communication with patients deemed to be high risk,” Perry said. “We also wanted to facilitate the coordination of care with primary care providers and selected specialties.”
Crystal Run implemented the screening protocol during patients’ orientation visit with the nurse practitioner (NP). NPs typically used the visit to review the treatment regimen, provide the OCM-mandated 13-point care plan to the patient, review advanced directives, screen for distress, and provide instructions for accessing care during and after hours. In addition, the visit allowed the NPs to use hot-spotting techniques to identify potential super utilizers. According to Perry, hot-spotted patients accounted for 10% of all of Crystal Run’s OCM patients.
The NPs blocked out 2 hours every day to call patients in the program twice a week. They chose 8 to 10 am because it was the quietest time of the day in the office, patients tended to still be at home, and the early window afforded time to still schedule an appointment or a consult. They offered same-day appointments as needed and documented any interventions in the electronic medical record to keep the oncologists informed of any changes. NPs used the calls as a preventive measure to check on patients before their conditions worsened.
“Our experience has been that patients frequently have symptoms for a substantial period of time before calling an office,” Perry said. “By the time they call, they’re often ill enough to require admission or proceed directly to the [ED].”
Patients often delay calling for help because they “don’t want to bother anyone” or they think the issue will resolve itself or do not realize how serious the symptom is, Perry explained.
“Without frequent, provider-initiated contact, the problem continues,” Perry added.
The details of Crystal Run’s program were later presented at the American Society of Clinical Oncology Annual Meeting, but Perry was able to disclose that inpatient admissions and costs are down and that patient feedback has been favorable.
Although the program has been successful, the focus of using NPs has been costly, and Crystal Run is modifying the program to be less expensive yet still maintain the quality and personal touch, Perry said.
A Payer’s Cancer Care Quality Program
Anthem did not participate in the OCM, but it did implement a cancer care quality program because it recognized that the quality of cancer care was inconsistent—it wasn’t aligned with best practices, there were unnecessary hospitalizations, and unneeded tests and treatments were putting patients at risk.
Instead of participating in the OCM, Anthem created its own model to transform cancer care by supporting care decisions that are evidence based, value based, and patient centered, explained Angela Martin, PharmD, provider clinical liaison, oncology and palliative care solutions, Anthem Inc., based in Richmond, Virginia. The goal was to collaborate with providers to improve the quality of care by promoting evidence-based and patient-centered care, appropriately align financial reimbursement to enhance care coordination and treatment planning, and lower total costs to improve access to quality and affordable care.
The resulting Cancer Care Quality Program is a voluntary prospective payment model in which providers are offered enhanced reimbursement for care coordination and treatment planning when treatment pathways are selected. The program includes approximately 15 million commercial and Medicare Advantage members and focuses on more than 17 types of cancer.
The providers follow Anthem’s own pathways, which are based on clinical efficacy, safety, toxicities, cost, and scientific advances. Ten medical oncologists are on an advisory council and have input into what regimens are on the pathway program. They also meet quarterly to review data and make any adjustments based on new guidelines.
Anthem meets with engaged practices quarterly to share their practice-specific data. It provides quality metrics for the practice as well as state and national benchmarks for items such as pathway adherence rate, percentage of patients admitted to the intensive care unit within the last 30 days of life, percentage of patients enrolled in hospice, number of ED visits per 1000, and average length of stay.
The program is having an impact. “There were better outcomes for members [who] were treated with regimens that were on pathways versus off pathways,” Martin said.
From 2014, when the program was launched, to 2017, ED visits dropped by 12%, hospitalizations were down 18%, average length of stay dropped by 20%, days in the intensive care unit were down 14%, and total medical costs were down 8%.
“We were really excited to see the data so we knew it [was] actually having an impact,” Martin said.