Andrew L. Pecora, MD, CPE: So the oncology care model has been launched by CMS. I actually wrote the successful application and got the grant for our group, and one of the things that struck me was that there was a lot more emphasis in the beginning on process than there was on actual clinical outcomes. You’re not measuring progression-free survival. Most doctors would say that what we’re measuring, really, has nothing to do with the quality of the care I give. Even oncology-specific issues are very, very rudimentary. They’re not at all sophisticated. Are you using the right targeted therapy, given this genetic mutation, etcetera, etcetera?
So, I’d like to discuss the Oncology Care Model (OCM). But I’d like also to put [things] in the context that oncology, unlike other fields, is evolving so rapidly and we’re learning so much, and actual care processes are changing. It would have been a nicety if you were an academic center, 5 years ago, to get a genomic profile on a lung cancer tumor. Now, it’s medical malpractice, if you don’t. What are some of the requirements under the OCM model?
Brenton Fargnoli, MD: I worked extensively on the OCM model. They break it into kind of 6 buckets of requirements to be eligible for the program—to be eligible for an additional “per-member per-month” payment, and to be eligible for shared savings in addition to the baseline fee-for-service. And [regarding] those requirements, there’s 3 that a lot of practices are doing already today. One is having an ONC (Office of the National Coordinator for Health Information Technology)-certified HER (electronic health records); 2 is having 24x7 access to a clinician who has access to your medical record. Many oncologists take call on the weekends and already have that system in place. The third [includes] a broad category of patient navigation. And within that, there’s several different layers of assisting with transportation, assisting with interpretation services, and other things.
Then there’s a whole other 3 that are fairly new to a lot of practices, and these have to do with quality measurement. As mentioned, there are quality measures that may or may not be measuring true outcomes, but there’s 13 sets of practice-reported quality measures. There is a 13-point Institute of Medicine care plan that has to be made for every patient in the program. [Then], the third piece is there is a requirement of guideline adherence and documentation of reasons for when the patients are going off of that guideline. So [regarding] those 3 pieces, we have found that practices are having to install a lot of new practice transformation, whether it’s people, or technology, or frankly both. Those are the 6 requirements in order to be eligible for participation in the program and the financial incentives that come with it.
Andrew L. Pecora, MD, CPE: I think that’s a good summary. So I’d like to ask you a question from your perspective as an economist. Again, looking at the role of the payer, either the government or private payers, they are all overseen by various agencies. When it’s CMS, it’s Congress. When it’s a private payer, it’s usually the Department of Insurance in a particular state. Obviously, reimbursement affects behavior. That’s the whole reason we’re changing reimbursement. But how do we assure the citizens of the United States and our patients that these changes are for the good, clinically? Patients come particularly to cancer doctors for one fundamental reason—they don’t want to die of their cancer. How do we assure that as we’re doing all these things, that if we’re not measuring the true outcomes that matter, that we’re not in fact…maybe we’re saving some money, but who’s responsible if we go down a road that saves some money but outcomes aren’t as good?
Rena M. Conti, PhD: Right. This is something that I think a lot about. The bottom line is that right now we’re in a situation where there’s a lot of overuse of care that doesn’t provide any clinical benefit to patients in terms of survival or quality of life. It is just built into the system. At the same time, a lot of care that does provide significant quality of life benefits, and maybe some mortality benefits, is underused or not used at all—depending on where you’re treated because of the financing. So the point of all of this change is to improve quality of care; to reduce overuse of services that we know cost a lot but frankly don’t do much, if anything at all, and potentially put patients at [risk for] harm; and increase the stuff that we know is good for patients and good for their families as well.