Bruce Feinberg, DO: Trials aside for a moment. Rich, in the microcosm—single institution, 1 doctor—there are these performance reviews; have you seen them all? Are you seeing them for your department? Do you know they exist? Has there been a formal reporting? Is there a monthly meeting? What’s taking place that’s bringing the rank and file doctor into this process?
Richard D. Carvajal, MD: We do have, during our divisional meetings every 6 months or so, an update on how we’re doing OCM [Oncology Care Model]-wise. So, we do see our own statistics.
Bruce Feinberg, DO: Every 6 months there’s a meeting. How long is the meeting?
Richard D. Carvajal, MD: It’s a piece of our 1 hour weekly meeting.
Bruce Feinberg, DO: It’s a piece of your 1 hour weekly meeting. I just wanted to get a sense. This is like when we talk about why we can’t make a difference in health care because the average patient is spending 10 minutes with their doctor once a year. What are you going to influence in 10 minutes a year? I’m just curious for that reason. I’m not picking on you in that way because, Rich, you’ve got the microcosm, and Ted, you’ve got the macrocosm, right? You’re seeing and hearing hundreds of practices give you feedback.
Ted Okon, MBA: I’ll give you the numbers.
Bruce Feinberg, DO: Yes.
Ted Okon, MBA: In the first performance period, 25% of the practices were what we call in the black, so black and red. Basically, you were either doing better than you should have or you were doing worse. Twenty-five percent were in the black, but only 20% were when there was a true-up. In the second performance period, 33% were in the black, but only 25% were when they did a true-up. For the third period reconciliation, the initial reconciliation is 35%. But you would suspect when the more claims come in, it will be a lower number....
Bruce Feinberg, DO: If you follow that reconciliation trend, our number is improving.
Ted Okon, MBA: Our number is improving, but what that means is, and this goes back to something that Kavita said, you’re dealing with basically 30% that are doing well by the measures and 70% that aren’t. They may have done well in 1 reconciliation period, not in another, and that’s what Kavita was roughly saying.
Bruce Feinberg, DO: Right, because there are very few that are consecutively in the black, isn’t that right?
Kavita K. Patel, MD, MS: Right, correct.
Ted Okon, MBA: That’s right.
Bruce Feinberg, DO: Which gets to a question of the sampling process, right?
Kavita K. Patel, MD, MS: Right.
Ted Okon, MBA: But still, my point is with that many that are in the red, even if they’ve been in the black for 1 period, it shows you that there are some issues with the program, or there are just a lot of practices that aren’t doing well.
Bruce Feinberg, DO: It gets into how we have sampling issues, and then we get into how it’s a moving target. Because the program’s initial design concept was, not related to IT [information technology], but rather a net neutral program in which you’re being measured against your peers.
Susan Ash-Lee, MSW, LCSW: That’s right.
Bruce Feinberg, DO: If everything is shifting to the right, and everything is improving, to stay in the black, you’ve got to do that much better than your peers you’re being measured against, correct?
Ted Okon, MBA: Yes, but the problem is, if you look at a true shared savings program, I’m either being measured against you or I’m being measured against the 4 of you. When you look at a gain-sharing program, you’re being measured against yourself. The OCM is like a little bit of both, but with a little bit more gain-sharing. I can tell you a practice, I won’t mention names, that has been in maybe 5 or 6 different commercial models and has done really well. I can tell you the practice is totally transformed. They haven’t done well in the OCM. Why? Because they’ve already done well. So to basically do better now....
Bruce Feinberg, DO: They were early adopters.
Ted Okon, MBA: But, you’re measured against yourself. It’s a real problem. As Kavita will tell you from a policy standpoint, this is what CMS [Centers for Medicare & Medicaid Services] has learned in terms of with some of the other programs. After 3 years, you can’t keep on measuring against yourself. You have to think about this differently.
Susan Ash-Lee, MSW, LCSW: There’s also a lag in when the practices get that data. Some of why you see this variability in how they’ve changed is they might have made a change based on that first level of data, but then you don’t see if it worked.
Bruce Feinberg, DO: You’ll skip 1.
Susan Ash-Lee, MSW, LCSW: That’s right. Did you put the right things in place during that performance measurement time?
Bruce Feinberg, DO: Do we have any patient outcome-related data? The metrics are cost and quality, but we don’t have clinical outcomes that we can tie to that yet, do we?
Kavita K. Patel, MD, MS: There is a clinical registry that everyone is required to put data into, but we don’t have outcomes from it.
Ted Okon, MBA: Data haven’t come out.
Susan Ash-Lee, MSW, LCSW: But we haven’t seen that.
Kavita K. Patel, MD, MS: There is clinical data there, which I have to commend CMS. For the first time they’re trying to do this. But the input, to Ted’s point, people have actually hired staff. Columbia [University Medical Center] is probably 1 of them. You’ve had to hire people to put that data in, which starts to get kind of counterintuitive. In the world of electronic health records, we’re still in our society not able to extract that information.
Ted Okon, MBA: I want to echo something that Susan said, that part of the problem of the program… this is a big undertaking of CMS and CMMI [Center for Medicare and Medicaid Innovation] to basically launch something like this. But part of the problem is the feedback is so lax that basically you have no clue. If you’re going to transform…. If I go, and I take a course somewhere, and 6 months later I get my grade, I don’t know how I could have done better. Not only that, you want to look at your grade and say, “Well, did I do well on the quizzes, or did I do poorly on the final? How about the oral piece of it?” That’s what’s missing from this program—both from the timeliness of the data and being able parse them down—in terms of what I can do differently and better to provide care.
Susan Ash-Lee, MSW, LCSW: It’s not a nimble program. You’re not going to make rapid changes because you don’t have the rapid feedback.