What will value-based oncology payment models look like now that the Oncology Care Model (OCM) has ended?
With the Enhancing Oncology Model (EOM) set to start July 1, 2023, Michael Diaz, MD, led a discussion on the transition to this new model during The American Journal of Managed Care®’s 11th Annual Patient-Centered Oncology Care® (PCOC) meeting held November 9-10, 2022, in Nashville, Tennessee. At the time of PCOC, Diaz served as president and managing physician at Florida Cancer Specialists & Research Institute (FCS).
Diaz asked panelists what they think is worth keeping in future oncology payment models, what didn’t work as well as hoped, and how relationships between practices and commercial payers have changed to reflect this shift to value-based care. Panelists were as follows:
What from OCM stays? To kick off the conversation, Diaz asked the panel which OCM elements were most successful and should be carried over into the EOM.
According to Patel, the most important process of the OCM that helped practices succeed was reducing the risk of emergency department visits. Under the OCM, he explained, CMS was able to put measures in place and use claims data to monitor how practices were performing in this key area, which affects both Medicare spending and patient quality of life.
Patel also mentioned the uptake and expansion of biosimilar use, which the model encouraged and should be carried over into the EOM.
It’s not just about the concrete practice changes, according to Lyss. He emphasized the importance of sustaining the cultural change and the commitment to value-based care and reimbursement models. To Lyss, this includes continuing to improve care quality and processes, building capabilities for data analytics—especially for claims data and clinical data—and adhering to clinical pathways, all while building this into the culture of a practice.
Responding to these points, Chong said the OCM has been a very positive experience for CMMI and CMS. She said CMMI leaders highly value the feedback on the OCM and the collaborative nature around the development of the EOM.
She also noted that CMMI and CMS are assessing which goals to prioritize with the EOM and which elements of the OCM will help meet those goals.
“I would say for certain that it really is focused on the patient,” Chong said. “I think so many of the requirements that we had in OCM—particularly around the enhanced services with the provision of MEOS [payments for monthly enhanced oncology services]—are really tailored to having a closer relationship with a patient, really focusing on that patient-centered care.”
Chong said CMMI has heard from practices that when they could provide services that are important to patient, the difference was clear. “It’s really important that OCM has allowed practices to finally provide the care that they want to provide—that is really centered and focused on the patient—with the resources to be able to do so,” she said.
Affordability is also a major factor to keep in mind with the development of the EOM, especially in the lens of health equity. Chong noted that the health equity strategy will be a more explicit component of the EOM. Although feedback on the strategy has been fairly similar across oncology practices—especially regarding the importance of reducing disparities in cancer care—there are varying levels of understanding of the practice expectations under the EOM.
The degree of prescriptiveness each practice will have regarding access to resources and physician and beneficiary buy-in under the EOM is not entirely clear, and understanding of this especially varies between practices that did and did not participate in the OCM.
To some practices, there are a lot of requirements for building up their infrastructure and implementing electronic patient-
reported outcomes, an increasingly popular tool in health care delivery. To others who may have had more time and resources to build up their infrastructure, this will not be as big of a challenge. According to Chong, it’s important to keep these differences in mind when potentially giving some practices more flexibility and time to improve their infrastructure than others.
Adding to this point, Lyss stressed the importance for CMMI to implement episode pricing adjustments to create benchmarks and demonstrate the economic viability of payment models for practices that did not participate in the OCM.
OCM inspires commercial payers. The OCM prompted many commercial payers to develop alternative payment models with similar features; many of these models are still operating even after the OCM has ended.
According to Lyss, certain models and contracts—including the Oncology Medical Home model supported by Community Oncology Alliance, the Bundled Payments for Care Improvement initiative, and the Blue Cross and Blue Shield of Minnesota and Minnesota Oncology value-based agreement—were successful because of the collaboration between practices and health plans.
“The thing that those three have in common that I think is worth noting is they were codeveloped with the practice and the health plan working together to iterate on OCM and develop a payment model that promoted value-based care and took advantage of the core capabilities of the practice to deliver value-based care,” Lyss said. “Where you have the health plan and a practice working together to design and implement those models, I think that’s really where kind of the recipe for success begins.”
Diaz added that more than 70% of patients treated at FCS were covered by some form of value-based arrangement toward the end of the OCM.
Adding to Patel’s earlier point about decreased hospitalizations under the OCM, Diaz said that FCS saw an 18% reduction in health care expenses per member per month in year 4 of its Florida Blue program compared with similar practices and programs in the market. The practice also saw a nearly 23% reduction in emergency department visits compared with a 5.4% reduction in the rest of the market.
What about chronic care management? Under the OCM, Chong saw much more restriction in allowing billing for both additional chronic care management codes and transitional care management codes for the same beneficiary in the same month.
“Because of a narrower cancer type in EOM, I think there are additional opportunities in which the provision of those types of enhanced services or the care coordination can still be cast out on a wider net,” Chong said. “But there are different opportunities in terms of the billing of those various codes because of the narrower cancer type.”
Building on this, Patel noted that if there is a patient with a Z code and with social determinants of health requiring certain needs, CMS provisions allow some patients to qualify for chronic care management codes. He added that doing this would show what is actionable and give insight into spending patterns for dual-eligible patients.
Interaction with MIPS. To close out the panel, Lyss noted that practices participating in the Merit-based Incentive Payment System (MIPS) but not in EOM will be at risk for capitated total costs of care, although there is accountability for total costs in either program.
As they decide where to participate, practices must consider degree of downside risk in each program, which is far greater in EOM than MIPS. For example, cost measures in MIPS do not include drug costs, but EOM episode prices do. Additionally, the weight of cost and quality performance are similar under MIPS, but quality is of more importance under the EOM.
As Lyss emphasized, practices need to look at all the considerations mentioned to decide whether to participate.