With the Oncology Care Model (OCM) slated to end in 2022, the successor model is still not in place. According to panelists, there is likely going to be a gap after OCM ends and the new model begins, but more importantly, practices should prepare for the new model to be mandatory.
After 5 years, the Oncology Care Model (OCM) is scheduled to come to an end in a few short months, but a successor program is not in place. During a panel at the Patient-Centered Oncology Care conference, experts dusted off their crystal balls to try to understand what might be coming next for value-based care in oncology.
The panelists were largely in agreement that there is going to be a gap between models and the next one will likely be mandatory.
They agreed that there is not enough time at this point for a new model to be put in place by the time OCM ends, creating a gap that practices will have to figure out how to get through. Originally, the successor to OCM was supposed to be the Oncology Care First model, but after it was initially revealed, little more has come out about it, explained Marcus Neubauer, MD, chief medical officer of The US Oncology Network.
A gap between models is concerning for practices that put in place a lot of changes and invested a lot of money in new ways to care for patients. Without a new model in place, practices are going to figure out how, or if, they can maintain those changes without the same payments, explained Stephen Schleicher, MD, MBA, medical oncologist at Tennessee Oncology and medical director of value-based care at OneOncology.
There is likely going to be at least some component of the next model that is mandatory, said Amy Valley, PharmD, vice president of clinical strategy and technology at Cardinal Health Specialty Solutions. She pointed to the recent radiation oncology model, which will be mandatory, as an example. However, a lot remains to be seen. For instance, the model may be limited to certain disease states.
Schleicher added that there has been research on the importance of mandatory models and how voluntary models result in selection bias. If there is a mandatory model, it might not be right away, which feeds back into his concerns about a gap, but a mandatory model is probably coming.
“If you're not prepared yet, you need to start thinking about that, because I do think there's a lot of hype on a mandatory model coming,” Schleicher said.
Kate Goodrich, MD, MHS, senior vice president for trend and analytics, clinical and pharmacy solutions at Humana, Inc, and formerly chief medical officer at CMS, highlighted 2 features in the new models that she expects to see and 2 that she hopes to see.
She expects to see something around care being rendered in the home, which would include telehealth, and she also expects something in the new model around equity and social determinants of health.
“So, how [equity] actually gets structurally built into the model will be very interesting to look out for, but I can't imagine that it won't be part of the model,” Goodrich said.
She hopes to see a meaningful incorporation of patient-centric outcome metrics, which will be hard, but also for the Center for Medicare and Medicaid Innovation (CMMI) to do a real assessment of organizational readiness to transform practices to be able to be successful in a risk-based payment model. In addition to the assessment, there may be an opportunity to provide assistance to get practices prepared.
A recent report from Abt found that OCM practices were not saving Medicare money, which Neubauer found sobering and frustrating, because most of the practices with The US Oncology Network are below the benchmark and are spending less money than they are expected to.
“I think the headlines didn’t match the experience,” Valley said, agreeing with Neubauer. The findings in the report were not in line with the experiences of many practices, which continued to improve patient care and transform their practices using payments from OCM.
While there are practices that had trouble performing well, the challenge with the report is that it generated such negative headlines and doesn’t allow for a path in the public eye to continue to innovate. The history of value-based care models is to take the learnings and build on them to improve.
“We’ve learned a lot with OCM through the investments,” Valley said. “We’ve learned what works and what hasn’t worked. And we should make sure we address those in whatever [model] comes forward.”
Schleicher added that the report is based on where practices were in OCM several performance periods ago. Since then, for instance, Tennessee Oncology has internalized palliative care programs and gained access to emergency department data. Both of those things were not true 2 or 3 years ago because it took time.
“It's all been in the last year, year and a half, that we kind of found our stride, and the data is just not capturing that,” he said.
Looking forward at ways to improve care more, Humana is starting to explore the use of additional digital and telehealth opportunities so patients can manage their disease in their homes, Goodrich said. The payer is also diving deeper into analytics on patients in order to segment the population and better understand their experience and care journey to better define the right interventions.
Schleicher has found commercial value-based plans useful because OCM has always had a delay with data. Practices often don’t know how they’re performing in the model until a year and a half later. While they can control their own workflows and interventions, practice performance in the model may be impacted by a new, expensive drug that came out. He is pushing for commercial plans, especially if there is a gap after OCM ends, to share data more rapidly so practices know how they are performing.
More granular data is also key, Schleicher said, and with commercial plans there is more agreement on treatment pathways. The high price tags of new drugs contribute to the risk. If the vast majority of patients are on a pathway and a very expensive therapy is being used correctly, payers and practices could potentially coordinate, reducing the risk to practices.
“Some of these new drugs that come out with high price tags really contribute to the risk in medical oncology that you don't see in other primary care–based chronic disease conditions,” he said.
Valley added that the pharmacy aspect has been a challenge in value-based care, in general. The pharmacy benefit is managed different than the medical benefit, and what happens is that a practice can put in place care coordination and make other investments, but when the prescription goes outside to a third party, the cost of care increases and the quality decreases.
“It's a poor patient experience. None of which is compatible with value-based care goals,” Valley said.
In general, Neubauer thinks there is going to be a shift with more providers accepting risk. When OCM first came out, there was a big cultural shift that had to take place, but over time it has happened. If there is a gap after OCM, a lot of practices will have to decide if they will continue providing services that were reimbursed under OCM, but that would no longer be reimbursed without a new model in place. Some practices may decide to keep providing those services, but some may decide to pull back.
Looking ahead to the next CMMI model to come after OCM, all of the panelists agreed that the cost of drugs have to be addressed. A lot of novel therapies go through the expediated approval process with the FDA and are approved based on surrogate end points, “but they haven’t shown themselves to be better than standard care in improving outcomes that matter to patients,” Goodrich said.
A future oncology model needs to incentivize “responsible adoption of novel therapies,” she said. When there are tried and true alternatives, the new model should incentivize oncologists to avoid the inappropriate prescribing of novel therapies that do not show improvements in outcomes.
Neubauer added that the drugs are the “elephant in the OCM room.” Drugs are a growing part of the cost, and any new model needs to address that in a more aggressive way.
Schleicher reiterated the need for more granular data, which can help the drug price issue. In addition, there should be a way to look a drugs separately: supportive care vs novel therapies vs old chemotherapies.
Finally, Valley suggested CMMI more aggressively incentivize the use of generics and biosimilars since biosimilars is an area where there have been savings. Similarly, medically integrated dispensaries are important and anyone in OCM should be in network for all prescriptions she said.
In addition, she circled back around to the idea that the next model will be mandatory. Even if it is, CMMI should continue to fund pilots that allow innovation to occur, she said.
“If we go to mandatory, we're not done. We're still learning,” she said. “There's still new ways to think about how we can advance value-based care. And so there should be funding for those types of innovations.”