COVID-19 has delayed the transition to Oncology Care First, but the forthcoming model could help.
In the months since the Oncology Care First (OCF) informal Request for Information (RFI) comment period closed in December 2019, America’s health care system has faced a reckoning. A series of alternative payment model (APM) updates made by the Center for Medicare & Medicaid Innovation (CMMI) in the wake of coronavirus disease 2019 (COVID-19) included a yearlong extension to the Oncology Care Model (OCM) and a delayed start of the OCF program.1 While downside risk exposure in voluntary APMs might give potential participants pause as they recover from the impact of COVID-19, there are 3 important ways this public health emergency ultimately makes this model and others like it more appealing.
Prospective Management Fees Bring Reliable Payment
Providers in capitated or semi-capitated payment arrangements are paid predetermined amounts to care for a population of patients. In these prospective payment arrangements, providers have incentives to deliver the most efficient care possible and benefit from a predictable source of funds amid fluctuation in volume.
A long-standing barrier to adoption of these and other value-based payment arrangements has been the sheer convenience of fee-for-service (FFS) reimbursement. However, COVID-19 showed that, in a matter of weeks, complacency in fee-for-volume payment was upended as elective services plummeted. While most providers faced debilitating drops in previously reliable revenue, organizations participating in prospective or global budget types of payment arrangements were better positioned to weather the impact of COVID-19.2
The revenue impact of COVID-19 on oncology is less severe than in clinical service areas such as orthopedics and primary care, but oncology is not immune. Data from the COVID and Cancer Research Network (CCRN), published by the Journal of Clinical Cancer Informatics in July, “clearly suggest a significant decrease in all cancer-related patient encounters as a result of the pandemic.”3
In retrospect, the OCF RFI reads as poetical foreshadowing in its description of CMMI’s goal to “eliminate reliance on volume-drive, FFS revenue cycle management” and test whether “predictable revenue streams through an alternative payment mechanism”4 improve care coordination and management for cancer patients. As conceptualized, the model would pay participants a prospective, monthly payment for an assigned population of patients being treated for cancer. This fixed amount would cover evaluation and management (E/M) services, drug
administration services, and other enhanced services such as care management and coordination. Participants also would be eligible for performance-based payments for quality and total cost of care accountability. Amid ongoing challenges to control the pandemic, a more reliable source of revenue may be welcome.
Legislation to Better Support APM Participation
COVID-19 provided real time feedback on the importance of value-based care (VBC) initiatives. Much of the care redesign activity and care management infrastructure that providers put in place for the purposes of being successful in VBC models enhanced providers’ ability to provide ongoing care for patients during the pandemic. While working with hundreds of providers across the country, Archway Health found that VBC participants were more likely to have in place hotlines staffed 24 hours a day, 7 days a week, with registered nurses; remote patient engagement tools; standardized use of a risk assessment tool to identify higher-risk patients; a process to review admit-discharge-transfer feeds from PatientPing or MemberMatch to determine which patients need follow-up; and other population health management strategies.
To inform these activities, VBC participants were more likely to have analyzed data for their patient populations and had a better understanding of the risk profile and prevalence of comorbidities
among their patients.
CMS recognizes the crucial role VBC has played in meeting patient needs during this pandemic. During a Deep Dive webinar on the “Future of APMs,” hosted in May by America’s Physician Groups (APG), CMMI Director Brad Smith noted, “The public health emergency we’re going through shows the importance of value-based care.”5 He also emphasized that because of the “type of skills and type of capabilities that organizations have built up as part of being part of value-based [models],” continuing to stay in these programs is “the right thing to do for patients.”5
In June, 6 former CMS leaders, including Mark McClellan, MD, PhD; Don Berwick, MD; and Andy Slavitt wrote congressional leadership calling for financial relief to help providers “adapt to the continuing threat of the virus and to rebuild care that keeps the best ideas for improving care in the pandemic.”6 They also recommended that relief funding be tied to provider efforts to move into value-based payment (VBP) models, and they “expect longer-term savings and better outcomes from greater participation in payment approaches that are better alternatives to FFS.”6
Calls for legislative reform to help drive adoption of APM participation have resonated. In late July, the Value in Health Care Act of 2020 (Value Act) was introduced in the House of Representatives.7
The bipartisan bill aims to accelerate Medicare’s move to VBP and increase participation in APMs through a number of legislative priorities, including extending the 5% bonus for advanced APM
participation for an additional 6 years and lowering the Qualifying APM Participant (QP) thresholds for performance year 2021 and onward. Specifically, the Value Act would set the QP payment threshold at 50% in performance year 2021 and limit the increase to no more than 5% each performance period thereafter—a substantial improvement compared with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) payment threshold of 75% in performance year 2021, and an opportunity for OCF participants to earn additional upside revenue beyond the prospective monthly management payments and performance based payments.
Leveraging Forced Innovation in Care Delivery
Ready or not, COVID-19 forced providers to adopt innovative ways to deliver care more efficiently. A prime example is the rampant adoption of telehealth, which allows cancer patients with compromised immune systems and high risk of infection to safely receive health care services. A McKinsey COVID-19 consumer survey found that telehealth adoption more than quadrupled between 2019 and April 2020, growing from 11% to 46% of US consumers using telehealth.8 During the virtual Community Oncology Association (COA) 2020 Conference in April, a virtual panel of leaders from oncology practices all agreed telehealth was a key pillar of their organization’s strategy to provide safe critical care for their patients under crisis conditions. Sibel Blau, MD, medical director of Northwest Medical Specialties, noted that telemedicine “improves patient care in ways that we couldn’t have imagined.”9 With implementation accomplished and plans for CMS to permanently expand telehealth for E/M Services,10 practices can leverage their existing infrastructure for care coordination in OCF.
Other COVID-19 initiated investments made to care redesign, such as home-based chronic care management, remote patient monitoring, partnerships with pharmacies that can deliver medications to patient homes, optimization of a rotating remote workforce, and ways to address lack of transportation for patients, may also generate earnings in OCF.
The reasons America’s health care system needs to implement a better way to pay for services are well-documented; the most disruptive pandemic in modern history may be what forces real reform.
Needing a crisis of this scale to bring broadscale change is regrettable. Worse would be our failure to continue moving in a better direction. In an April Health Affairs article, Mark McClellan, MD, PhD, and coauthors explained, “Continued payment reform progress is in the current interests of public health.”11 If designed well, OCF could be 1 of many worthwhile steps to take in that journey.
Keely Macmillan, MSPH, is senior vice president, Policy and
Solutions Management, Archway Health.
1. Verma S. New CMS payment model flexibilities for COVID-19. Health Affairs blog. June 3, 2020. Accessed June 3, 2020. https://www.healthaffairs.
2. APM participants appear better positioned for COVID-19. Archway
Health blog. May 7, 2020. Accessed September 26, 2020. https://www.
3. London JW, Fazio-Eynullayeva E, Palchuk MB, Sankey MB, McNair C.
Effects of the COVID-19 pandemic on cancer-related patient encounters.
JCO Clin Cancer Inform. 2020;4:657-665. doi:10.1200/CCI.20.00068
4. Oncology Care First Model: informal request for information. CMS.
November 1, 2019. Accessed November 1, 2019. https://innovation.cms.
5. CMMI director Brad Smith underscores Medicare’s commitment
to value-based care. Archway Health blog. May 26, 2020. Accessed
September 26, 2020. https://www.archwayhealth.com/bundled-payments-
6. Former CMS leaders write to Congressional leaders about payment
and regulatory flexibility in COVID-19. Primary Care Collaborative.
June 12, 2020. Accessed September 26, 2020. https://www.pcpcc.
7. HR 7791. Value in Health Care Act of 2020. 116th Congress. 2nd sess.
8. Bestsennyy O, Gilbert G, Harris A, Rost J. Telehealth: a quarter-trillion-dollar post–COVID-19 reality? McKinsey & Company. May 29, 2020.
Accessed September 27, 2020. https://www.mckinsey.com/industries/
9. Doyle C. Cancer versus COVID-19: telemedicine, financial fallout, and
the future of community oncology care. May 2020. https://obroncology.
10. Trump administration proposes to expand telehealth benefits
permanently for Medicare beneficiaries beyond the COVID-19 public
health emergency and advances access to care in rural areas. News
release. CMS. August 3, 2020. Accessed September 27, 2020. https://
11. Bleser WK, Singletary E, Crook HL, Gonzalez-Smith J, Saunders
RS, McClellan MB. Maintaining progress toward accountable care
and payment reform during a pandemic, part 1: utilization and
financial impact. Health Affairs blog. April 14, 2020. doi:10.1377/hblog20200410.281882.