Implementing alternative payment models in oncology is a complicated process. The models are not perfect, especially the Centers for Medicare and Medicaid Services’ Oncology Care Model (OCM), although several panelists saw improvements in the proposed successor model, Oncology Care First (OCF).
When LALAN WILFONG, MD, was approached with the offer, “Hey, want to do some quality work?” His reply was, “Oh, that sounds like fun.”
A few chuckles fi ltered through the room as Wilfong shared this story during “Future of Oncology Advanced Alternative Payment Models,” in the afternoon session of Patient-Centered Oncology Care®. But Wilfong, who now serves as executive vice president for Value-based Care and Quality Programs at Texas Oncology,
said his motivation for taking on “quality work,” or helping a 490-physician practice transition to alternate payment models (APMs), was a long time coming.
“One of the things I struggled with from the time I started medicine in private practice was the fee-for-service [FFS] model. I always felt it was wrong,” said Wilfong, who believed the premise of “turning patients through to get paid” was counter to his objective of giving all patients the level of care they needed.
KASHYAP PATEL, MD.
The idea that doctors should be rewarded based on how patients respond to treatment and the quality of their experience, all at a reasonable cost, is behind the goal of moving to an APM. But progressing from FFS to APMs in a way that’s fair for doctors and patients has been easier said than done, panelists shared during the session, led by meeting cochair
In addition to Wilfong and Patel, the panelists were:
STEVEN D’AMATO, RPH, BS PHARM, BCOP
, executive director and clinical pharmacy specialist at New England Cancer Specialists, based in Maine;
director of Provider Collaboration Programs at Anthem; and
RANI KHETARPAL, MBA,
vice president, Oncology Value-Based Partnerships at New Century Health.
The bottom line from all the panelists? Implementing APMs in oncology is a complicated process. The models are not perfect, especially the Centers for Medicare and Medicaid Services’ Oncology Care Model (OCM), although several panelists saw improvements in the proposed successor model, Oncology Care First (OCF).
“There’s a lot to learn and a lot to implement along the way,” D’Amato said. OCM has been a “great fi rst step” in redefining how practices think about care delivery. “There have been massive changes that have occurred due to the OCM. But I do believe that OCM is a fl awed model.”
Others agreed with D’Amato that the “elephant in the room is the drugs.” For all the positive changes made in promoting care coordination, care planning, palliative care, and quality measurement, the model suff ers greatly from the “data lag,” both for tracking drug prices so practices can be paid correctly, and for letting practices know how they are doing so they can make changes.
“We have to fi gure out a way to keep oncology providers whole and in order, to support the services that we provide and enhance the services,” Wilfong said.
Odell pointed out that the OCM is not the only APM in cancer care; he directs Anthem’s oncology medical home model, and the payer is looking at the
OCF. He’s also considering bundled payments and the successes in primary care with the patient-centered medical home for improvements.
Khetarpal said her company, New Century Health, is known for aligning with payers, and her role is to lead the alignment with providers as well.
“There is a tremendous opportunity for providers to be in the driver’s seat as current APM models are being developed,” she said. Over the next 1 to 3 years, it will be critical for these groups to work together on payment model reform instead of allowing models to develop in “silos.”
Patel asked D’Amato what he would recommend to the Center for Medicare and Medicaid Innovation (CMMI) to avoid the phenomenon of practices being “punished” for having too many patients with certain high-cost cancers. D’Amato agreed that this must addressed, and that having all the data the OCM has produced shows “there’s no getting around the drug costs.”
“When you look at the total cost of care today [in] our particular geographic area, [the drug cost] approaches 70% of the total cost of care. That’s a huge amount of money,” D’Amato said. Practices that were already effi cient were getting measured against themselves.
“I knew we were dead coming out the gate,” he said. CMMI must create a model that works to “level the playing field.”
Besides dealing with compensation for drug costs, panelists said oncology APMs, and the successor to OCM in particular, must do more to address patient
attribution and transparency. Wilfong said it appears that CMMI has “listened to us” in revising the OCF to address low-risk patients—patients who are seen
infrequently, for whom practices should not assume the risk. Instead, he believes the risk should stay with the primary care practice.
But the future of APMs will come down to having an appropriate system for how practices are evaluated for spending on drugs. D’Amato and Wilfong agreed that biosimilars have a role to play; however, practices should not be forced to carry 4 or 5 options of a reference product to accommodate various payers. If practices assume the risk, then let them decide, they said. If immunotherapy is needed for a patient with lung cancer, physicians should prescribe it without worrying that the pricing doesn’t fi t the model.
“That’s the thing we have to fi gure out: How do we hold physicians accountable for drug [costs] when [we] need to be held accountable, but not hold us
accountable when it truly is time for us to do novel therapies?” Wilfong asked.
“When, at the end of the day, the physician’s responsibility is to their patients, to provide them with the best care that they can based on the patient’s goals and values in a setting of shared decision-making, that’s my job,” he said. “My job isn’t to withhold care from a patient who may benefit from care.”