Oncology practices participating in the Centers for Medicare & Medicaid Innovation’s Oncology Care Model (OCM) are willing to take on two-sided risk, according to the results of a survey conducted by the Community Oncology Alliance (COA), a nonprofit organization dedicated to advocating for community oncology practices. The COA said the results suggest that oncology practices are confident they can succeed in delivering high-quality and cost-effective cancer care as the health care system undergoes a paradigm shift from fee-for-service to value-based care.
COA surveyed OCM participants following the CMMI Dec. 3, 2019, deadline, by which practices had to decide whether to continue in the OCM program, as well as to commit to two-sided risk going forward. A total of 68 OCM practices responded to the 15-question survey, which found:
• 47.1% (32 practices) opted to remain in the OCM with one-sided risk
• 36.8% (25 practices) chose to remain and enter into two-sided risk
• 32.4% (22 of the 25 practices) selected two-sided risk and had not received a single performance-based payment
• 16% (11 practices) said they were dropping out of the OCM
• Ten of the 11 practices leaving the OCM had not received a performance-based payment over the preceding four performance periods
• One practice indicated it had received at least one performance-based payment but opted to leave the OCM
Since the start of the OCM, COA has had more than 80 percent of OCM participants networked in an interactive “OCM Support Network” that includes regular calls and meetings, a dedicated listserv, access to subject matter experts, and more.
Following the Dec. 3 deadline, only OCM teams that had received at least one performance-based payment (out of a possible four performance-based payments) could remain in the OCM without accepting two-sided risk. If practices remained in the OCM, they had to decide between one-sided risk or taking on two-sided risk. With two-sided risk, practices would have to pay back Medicare if they did not achieve the required cost savings. Practices that have not received a performance-based payment but wished to remain in the OCM were required to enter a two-sided risk arrangement.
Practices remaining in the OCM and taking on two-sided risk represent 679 physicians. The average practice size that is assuming two-sided risk is 29.5 physicians. The largest practice taking on two-sided risk in the survey has 160 physicians, and the smallest practice has two physicians.
According to COA’s Director of Strategic Initiatives, Bo Gamble, the survey results show that oncology teams have gained confidence with new models of cancer care. “The last three and a half years have done much to educate and prepare teams for new models for cancer care,” Gamble said in a prepared statement. “No longer are incentives purely about utilization. Now there are numerous attempts to design a model with emphasis on quality, value, and meaningful quantifiable outcomes. The OCM, and the 20-plus other models, are consistent with that message.”
The OCM has had a transformative effect on community oncology practices, but implementation has been challenging, even for practices with previous payment reform experience.
COA’s efforts to support and advocate for the OCM practices that have been struggling with implementation eventually led COA to begin developing its own payment model for cancer care based on quality and value. Known as the “OCM 2.0,” it is a detailed alternative payment model (APM) that includes bold proposals for value-based drug contracts that, if implemented, would provide high-quality, coordinated oncology care at the same or lower cost.
COA’s Response to Oncology Care First
In early November 2019 the Centers for Medicare & Medicaid Services and CMMI published an informal Request for Information about what they call the “Oncology Care First Model (OCF),” their follow-up to the Oncology Care Model that expires in 2021.
The Community Oncology Alliance shared several concerns. “We remain very concerned about the proposed timeline to begin OCF Model implementation on January 1, 2021. We believe the proposed timeline is not feasible for both participating OCM practices and practices attempting to apply for OCF Model participation without prior participation in the OCM. Some practices have only just accepted a shift to down-side risk in the OCM, and most have not yet received substantial data to help them understand their performance in two-sided risk. Forcing practices with OCM experience to immediately join two-sided risk in the OCF Model would expose practices to significant volatility due to a range of uncertainties in the proposed payment methodology.” COA called the proposed timeline “completely unrealistic.”
COA recommends that CMMI delay the proposed start date of the OCF by one year to January 1, 2022, add two additional performance periods to the current OCM to ensure continuity of episodes, allow existing OCM participants to participate in one-sided risk for the first year of the OCF, and extend the period to which new participants can participate in one-sided risk by an additional year.
COA also notes that utilization of certified EHR technology vendors would still be required under the OCF Model framework, but COA advocates for CMMI to first verify the ability of each CEHRT vendor for their capacity to support model operations. “Many OCM stakeholders, including members of COA’s Oncology Payment Reform Committee, have noted that CMS did not seek to verify the ability of EHR vendors to adequately support practices. Moving from the OCM to the OCF Model, CMMI could better engage with the entire stakeholder community that interacts with model beneficiaries, including the CEHRT vendors, to be able to adequately support the practices in necessary data collection efforts around cost and quality measures.”
Also, regarding potential gradual implementation of electronic patient-reported outcomes (ePROs), COA recommends a ramp-up period in utilization of ePROs for all OCF Model participants. “COA knows that many community oncology practices have invested substantially in ePRO technology; however, there are many practices that would not be financially or operationally prepared should ePRO utilization be required from OCF.”
