With No Replacement for OCM on Horizon, Oncology Practices Ask: What Now?

Evidence-Based Oncology, December 2021, Volume 27, Issue 9

SAP Partners | <b>OneOncology</b>

The announcement of a "strategic refresh" for payment models under the Center for Medicare and Medicaid Innovation offered no details on what practices should expect when the Oncology Care Model (OCM) expires in 2022.

If oncology practices expected an explanation from CMS on next steps following the imminent end of the Oncology Care Model (OCM) during CMS Innovation Center’s (CMMI’s) announcement of a “strategic refresh” earlier this year, they may have been disappointed.1

The OCM, which began in 2016, has an anticipated performance period end date of June 2022.2 For many participating practices, what follows is up in the air.

“I think a lot of us had the expectation there would be a gap, and I think the lack of hearing anything otherwise just makes it more [clear] that there will be a gap,” said Stephen M. Schleicher, MD, MBA, a medical oncologist at Tennessee Oncology and medical director of value-based care at OneOncology. “I’m afraid that priority on a next-generation cancer model may be even more delayed than some of us had hoped.”

As part of its strategic refresh announcement, Elizabeth Fowler, PhD, JD, deputy administrator of CMS and director of CMMI, said the center did not plan to end any models early, although objectives of the refresh will guide revisions to existing models and consideration of future models.

The new approach will also focus on a “streamlined portfolio of models,” as the previous volume led to confusion among participating practices. “In addition to reducing overlap, we also want our models to be simpler and easier to participate in, with less administrative burden,” Fowler said.

CMS declined to comment directly for this article. A spokesperson said there is likely to be some gap between the end of OCM and the start of any potential oncology model.

Uncertainty Grows

This raises a myriad of challenges and questions for those enrolled in OCM who have complied with data reporting and operational requirements for the past 5 years. When it launched, OCM was to expire in 2021, but due to the pandemic, a proposed successor model called Oncology Care First was shelved.

“It actually feels more like a void than merely a potential gap in the comprehensive care that a lot of patients are now receiving and benefiting from under this model,” said Karen L. van Caulil, PhD, president and CEO of the Florida Alliance for Healthcare Value.

Intended to increase value-based care in the oncology field, OCM provides participants with monthly enhanced oncology services (MEOS) payments in addition to regular fee-for-service Medicare payments. Whether practices will receive bridge payments to continue funding services such as navigators and 24/7 record access until a new model is implemented remains to be seen.

“What do you do when you don’t have those payments anymore?” asked Schleicher. “We’re lucky Tennessee Oncology is very large, and we will continue to provide high-quality care that we’ve learned to do through OCM. But if you’re a small practice, I worry, are practices going to have to revert back to the old ways of doing things where they don’t have support from Medicare along the way?”

Amid this uncertainty, the Community Oncology Alliance (COA) called on CMMI to extend OCM through December 31, 2022.3 In a letter sent November 16, the group cited the investment that practices have made in the model, along with the effect the model has had on patient care. COA also argued that some negative reviews of OCM, notably the Abt Associates’ evaluation, failed to capture later data that show practices became better at implementing the model over time.4

“The millions of dollars of taxpayers’ money invested in the OCM and the dramatic successes of many independent community oncology practices participating in the OCM in enhancing patient cancer care while lowering treatment costs should be clear reasons why the OCM should not be trashed, but refined and reenvisioned based on what is working,” the letter stated. COA strongly endorsed CMMI’s call to focus on health equity in a future model.

This move received support from the Florida Alliance for Healthcare Value. “We think that's a very reasonable and appropriate request [by COA], rather than to just completely stop the program entirely,” said van Caulil.

Higher quality, more coordinated care at the same or lower cost than Medicare, was the primary target of OCM; the voluntary model also allowed practices to opt into 1- or 2-sided risk.

Absence of OCM raises regulatory compliance issues as well. Once the model ends, the possibility is raised that by default, OCM practices would be governed by other elements of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Under MACRA, if practices were enrolled in an alternative payment model (APM), they did not have to abide by the Merit-Based Incentive Payment System (MIPS).5 But if OCM expires and practices find themselves no longer enrolled in an APM, it is unclear if that fact compels MIPS participation.

Challenges in OCM

Despite mixed reports of success with the model, various shortcomings hindered efficient implementation and participation for some practices and ought to be addressed in future iterations, experts argued.

Because of OCM’s structure, participation in the model could disincentivize providing care for underserved communities or high-risk patients. Despite meeting reporting requirements and following guidelines, practices serving populations with baseline poor health would necessarily have increased risks of worse overall outcomes compared with practices serving healthier populations. A paper presented at the 2021 meeting of the American Society of Clinical Oncology found, for example, that high-risk patients were, on average, $21,500 over target when undergoing autologous stem cell transplant, even with risk adjustment for this procedure.

“Provider exposure to risk in the OCM is highly sensitive to factors at the cancer and patient level,” wrote the authors, who called for models that “model risk in more clinically granular ways.”6

In their strategic refresh, CMMI acknowledged this problem, which was also apparent in earlier additional models.

“My vision for the future of the agency, our programs, and the people we serve is straightforward: that CMS serve the public as a trusted partner and steward, dedicated to advancing health equity, expanding coverage, and improving health outcomes,” said CMS Administrator Chiquita Brooks-LaSure during the refresh announcement.

Among lessons learned listed in an accompanying CMMI whitepaper, the center stressed that moving forward, health equity will be embedded into every model. This step was seen by many as encouraging.7

“So far, models have focused on cost, quality, and patient experience. [Adding] equity as one of the factors is a welcome change,” said Kashyap Patel, MD, CEO of the Carolina Blood and Cancer Care Associates, associate editor of Evidence-Based Oncology, and president of COA.

But rising treatment costs in the oncology space also posed a challenge to practices. OCM includes a reimbursement system based on a snapshot of time to calculate reimbursement rates for oncology treatments. Over the years as new, more expensive treatments were developed and approved, they were, at times, not accurately captured by the model. The model was so ill-equipped to handle major innovations that CMMI initially did not even include chimeric antigen receptor T-cell therapy in the cost-of-care calculations.8

Cancer is a multifaceted disease with numerous variations, types, and mutations. This heterogeneity complicates standardization of care—a key component of other, more streamlined payment models.

CMMI plans to begin the Radiation Oncology (RO) Model in January 2022,9 a start date the American Society for Radiation Oncology has deemed “extremely challenging,” due in part to recently permitted cuts in Medicare fee schedules.10

The RO model “tests whether prospective, site-neutral, modality-agnostic, episode-based payments to physician group practices, hospital outpatient departments, and freestanding radiation therapy centers for radiotherapy episodes of care [reduce] Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries.”10

Under this model, there are limited options for treatment, and its mandatory nature encourages uniformity across practices. However, compulsory participation brings along its own challenges.

It is unclear if OCM’s successor will be mandatory. Although this change would remove selection bias when it comes to covering certain patient populations, a mandatory model would also impose onerous data-reporting requirements on smaller practices with less resources and manpower, adding to compliance hurdles.

On the flipside, voluntary models allow practices to simply drop out at the first hint of a bleak financial forecast, limiting the quality and quantity of data produced by model participation.

During OCM’s 5-year implementation, changing conditions required by CMS and a lag in outcome reports meant practices were unable to implement successful practices in a timely fashion.

Looking Ahead

Moving forward, CMMI plans to increase stakeholder perspectives and feedback on model successes and challenges via listening sessions hosted throughout the year—the first of which took place on November 18.

During this session, Lalan Wilfong, MD, vice president of care relations and practice transformation at McKesson and a medical oncologist and hematologist at Texas Oncology, laid out some complications of OCM and subsequent RO model participation.

Wilfong discussed how these practices will have to submit data for the mandatory RO model through a different platform than that used for OCM. This inconsistency presents a hurdle for practices as it took some years to optimize data reporting procedures to minimize compliance burdens.

With a new data reporting format under the RO model, “it feels like we have to start over again,” Wilfong said. But improved alignment from CMMI in the future may help alleviate these challenges and enable model participation, he added.

Touching on the heterogeneity of cancer care, Wilfong explained how historical benchmarks may not accurately reflect the current care provided. For example, at the start of the OCM, lung cancer care was “very simple in the management at that time,” but over the past few years, has seen “tremendous innovation.”

“My care paths for patients with lung cancer are very complex now, where they used to be pretty simple, with very different costs and outcomes and toxicities that we manage,” Wilfong said. Putting appropriate benchmarks in place for oncology patients that reflect the changing nature of the treatment landscape will help encourage rural and smaller practices to participate in future models.

Although this session was broad in scope, in upcoming discussions stakeholders may be eager to know whether practices that invested in models and reported success will be recognized in future or replacement models.

“If you want to continue to garner enthusiasm for participating in APMs and get people excited about it, there needs to be some recognition of groups that did double down on OCM—the first of its type—and especially the ones that are taking 2-sided risk,” said Schleicher. “It is frustrating for us in that boat who made all these large practice-transformation efforts, and hired new teams, and invested in analytics, and have been messaging to everybody around us how important this is to then feel like the rug got ripped from below us.”

Before practices invest in infrastructure and change how they operate in preparation for the next model, the concern is they participate for a few years, the model ends, and what comes next is unknown, he explained.

Overall, Schleicher does not think OCM was a failure and hopes it doesn’t get remembered as such, stressing the model resulted in improved care and cost savings for Tennessee Oncology.

Using MEOS payments, the practice was able to better reach rural patients and help them navigate a complex care journey by creating a new health care infrastructure that incorporates care coordination and data analytics. Performing well in OCM also enabled the practice to take on major goals of accountable care organizations, including keeping patients out of hospitals and improving end-of-life care.

In fact, as EBO went to press, Tennessee Oncology received word that for the period spanning the second half of 2019 and the first half of 2020, the community practice received a 100% quality score under the model, for metrics that include patient pain, depression assessment and management, reduction in emergency department visits, and appropriate use of hospice. Tennessee Oncology also saved Medicare $5 million during this period, according to an emailed news release.11

Schleicher aims to continue these efforts even after OCM ends. “It’s the right thing to do for patients….I think OCM was a success for groups like us,” he said. “We learned how to provide better care, and we couldn’t have done that without this model.”

Hayden E. Klein contributed to this report.

References

1. Melillo G, Caffrey M. CMS announces “refresh” of CMMI with focus on health equity, fewer models. The American Journal of Managed Care®. October 20, 2021. Accessed November 15, 2021. https://www.ajmc.com/view/cms-announces-refresh-of-cmmi-with-focus-on-health-equity-fewer-models

2. Oncology Care Model. CMS. Updated November 9, 2021. Accessed November 16, 2021. https://innovation.cms.gov/innovation-models/oncology-care

3. COA letter to CMS and CMMI requesting extension of OCM. Community Oncology Alliance. November 15, 2021. Accessed November 16, 2021. https://communityoncology.org/coa-letter-to-cms-and-cmmi-requesting-extension-of-ocm/

4. Abt Associates. Evaluation of the Oncology Care Model: Performance Periods 1-5. CMS; January 2021. Accessed November 16, 2021. https://innovation.cms.gov/data-and-reports/2021/ocm-evaluation-pp1-5

5. Understanding Medicare’s Merit-based Incentive Payment System (MIPS). American Medical Association. Accessed November 16, 2021. https://www.ama-assn.org/practice-management/payment-delivery-models/understanding-medicare-s-merit-based-incentive-payment

6. Chaudhry BI, Yue A, Kaila S, et al. Impact of cancer- and patient-level factors on provider risk in the Oncology Care Model. J Clin Oncol. 2021;39(suppl 15):e18852 doi:10.1200/JCO.2021.39.15_suppl.e18852

7. Innovation Center Strategy Refresh. CMS; October 2021. Accessed November 16, 2021. https://innovation.cms.gov/strategic-direction-whitepaper

8. Caffrey M. Paying for innovation in cancer care means no easy answers. The American Journal of Managed Care®. June 28, 2018. Accessed November 16, 2021. https://www.ajmc.com/view/paying-for-innovation-in-cancer-care-means-no-easy-answers

9. Radiation Oncology Model. CMS. Updated November 16, 2021. Accessed November 16, 2021. https://innovation.cms.gov/innovation-models/radiation-oncology-model

10. CMS 2022 final rules: ASTRO deeply concerned and disappointed, emphasizes need for legislative solution. News release. American Society for Radiation Oncology. November 2, 2021. Accessed November 16, 2021. https://www.astro.org/News-and-Publications/News-and-Media-Center/News-Releases/2021/CMS-2022-final-rules-ASTRO-deeply-concerned-and-di

11. Tennessee Oncology receives perfect quality score while saving Medicare $5 million during the last year of the Oncology Care Model. News release sent November 18, 2021, via email.