By: Jill Sederstrom
Just over a year after The Center for Medicare & Medicaid Innovation's Oncology Care Model (OCM) was rolled out in 192 practices across the United States, participating practices are reporting improvements to quality of care and reductions in emergency room visits for cancer patients as a result of the model.
“We've always sought to deliver high-quality care, without compromise, in a community-based setting,” Lalan Wilfong, MD, medical director of quality programs for Texas Oncology, one of the participating practices, said. “OCM is making us better at that.”
These early successes seen in some of the participating practices are a positive sign for the new payment model; however, practices also point to significant data reporting requirements and costly information technology needs to implement the program. Although the program is just wrapping up its initial year in practice, it is also not possible to gauge the overall success of the program yet as participating practices won't be reporting their first year's performance results until September.
The Model
The goal of the OCM model is to align financial incentives to improve care coordination, access to care, and appropriateness of care for cancer patients undergoing chemotherapy.
While other bundled payment programs such as Bundled Payments for Care Improvement (BPCI) allow practices to accept risk to treat chronic conditions, OCM includes financial incentives based on 6-month episodes that begin with the start of chemotherapy treatment.
"OCM is unique in that the program features a longer episode of care, 6 months, and in its comprehensiveness," Jessica Walradt, MS, lead payment reform specialist with the Association of American Medical Colleges, said. "Nearly every type of cancer can trigger an episode in OCM."
Participating practices receive a per-beneficiary monthly enhanced oncology services (MEOS) payment of $160 per month, while also having the potential to earn other performance-based incentives.
"Financially there's the ability to not only generate more revenue than they are currently generating if they are able to succeed based on the incentives, but also be paid differently, and a little bit more holistically, based upon the unit of care as the patient as opposed to individual services," Jeff Clough, MD, MBA, assistant professor of medicine at Duke University School of Medicine, explained.
Getting Started
Texas Oncology first implemented a pilot OCM program at its Waco clinics in early 2016, before fully implementing the program into 175 sites of service later that year in June.
To meet the program's requirements, Texas Oncology enhanced its patient navigation services, improved after treatment follow-up practices, expanded survivorship and advanced care planning programs, increased shared decision making, and enhanced its services to discuss the cost of care with patients.
“A treatment plan was created that gives patients information about their disease, treatment regimen and expected response to therapy,” Dr Wilfong said.
Lahey Health also ensured they were offering those program requirements when they began the program in July 2016.
Linda Weller Newcomb, Vice President of the Lahey Health Cancer Institute, said while they were already doing many of the core activities required by the OCM model, the health system didn't have the infrastructure built-in to demonstrate compliance with those requirements.
For them, the biggest challenge wasn't providing the care or patient services, but rather implementing and enhancing IT infrastructure and reporting mechanisms to be able to report to CMS that the services were being provided. According to Ms. Walradt, this is one of the programs biggest challenges for most practices.
“The quality and clinical measure data reporting requirements pose a considerable challenge,” she said. “While CMS has responded to feedback by altering requirements and deadlines, practices are still dedicating significant time to understanding measure specifications, building the necessary IT infrastructure, and accurately identifying patients for reporting.”
Impacts to Quality and Cost
Lahey Health also implemented specific initiatives aimed at improving the quality of care they provided patients, while also reducing unplanned admissions and emergency room visits.
For instance, they developed nurse navigation triage pathways and hired nurse navigators to serve as disease experts and a first point-of-contact for patients.
“We did this huge ‘call me first’ campaign,” Ms Weller Newcomb said, adding that they also created very regimented triage pathways for treatment.
In addition, they developed a five-level risk stratification system that gives patients a risk score based on issues like whether they have a co-morbid condition that could increase their likelihood of an emergency room visit or unplanned trip to the hospital. This risk score is then noted in a banner that runs at the top of the Epic system so that nurse navigators are very easily able to identify high-risk patients.
“We're really trying to proactively manage patients very differently,” Ms. Weller Newcomb said.
It's too early to tell the full impact these changes will have on both quality and cost, but Ms Weller Newcomb explained they've already seen improvements in both quality and cost anecdotally.
Texas Oncology believes by playing a greater role in its patients' cancer journey, it has also seen a reduction in emergency room admissions.
“Changes in clinic workflows due to the OCM increase access to our physicians and clinics, which helps patients avoid trips to the emergency room or hospital,” Dr Wilfong said.
Dr Clough explained that like most comprehensive models, it will take time to see the model's true value and its potential impact on care.
“It's a little slow going because in the beginning there's not clear evidence as to what works, providers are pretty hesitant to make large scale changes and incentives may not be strong enough either if you really want to change care,” he said.
Another advantage for participating providers, however, is the amount of Medicare claims data that they receive through the program. Ms Walradt said this data helps practices understand the totality of care received by cancer patients, including care that is received outside of their health system.
“The ability to both drill down into a single patient's care and identify broad utilization and cost trends enables practices to pursue data-driven care interventions,” she said.
Weller Newcomb said having access at the Lahey Health Cancer Institute to high quality metrics on a quarterly basis that include metrics such as how many people received chemotherapy in their last thirty days of life helps the center develop a more comprehensive picture of care and see a more holistic picture.
The initial practices involved also have the ability to shape and influence how the program evolves in the years ahead.
“We would rather be on the front end and partnering with CMS so we can impact what they are doing and where they are going with the program and how they fashion the program because otherwise it's going to be developed for you and you really don't have a say at the table,” Ms Weller Newcomb said.
Remaining Challenges
While some practices are initially reporting satisfaction with the OCM model, experts say challenges still exist with the program. Aside from the data reporting requirements, Melissa Porter, a senior associate with Leavitt Partners, said the OCM model makes it more difficult to control costs than the American Society of Clinical Oncology (ASCO) model and it has no real time tracking built into the system.
The consulting firm has also heard there may be more of an incentive to game the system because OCM is linked to six-month episodes.
Smaller practices may also lack the economies of scale of some of the larger practices to be able to meet the needs of the OCM model, while also reducing costs. Ms
Porter also noted some attrition, among both payers and providers, since the program began as well.
“Already we are hearing of some winners and some losers,” she said.
Future Ahead
Experts agree that the OCM model is still in the early stages and it will take time before its impacts can be fully evaluated.
“Once CMS collects providers' clinical data, they will explore ways to create better risk-adjusted target prices,” Ms Walradt said.
This process will be crucial, she explained, because clinical factors such as stage and molecular mutations are significant determinants in a patient's treatment plan and costs but are not available in claims data and aren't being used in the current OCM target price methodology.
But while the full picture may not be clear, at least for some practices, the OCM model has delivered some initial successes.
"It's improving our collaboration, sharpening our focus on the patient's complete needs—during and after treatment. And it helps give the patient a stronger voice in their treatment journey," Dr Wilfong said.
Read the full story at First Report Managed Care.