May 2017 Edition Vol.11, Issue 5

Hypothetical OCM. 2.0 Addresses Obstacles and Opportunities

By Megan Garlapow, PhD

In a presentation at the 2017 Community Oncology Conference held April 27-28 in National Harbor, MD, Kavita Patel, MD, Nonresident Senior Fellow at the Brookings Institution and primary care physician at the Johns Hopkins Community Physician Practice at Sibley Hospital in Washington D.C., and Ted Okon, MBA, Executive Director of COA, described desired changes to improve upon the OCM and dubbed these changes “OCM 2.0.”

Patel noted that a single, “one-stop” solution would not be viable for modifying the current OCM. She suggested that a broad set of solutions could offer a payment model in oncology that could support patients, providers, and payers.

A criticism of the OCM is that it is limited to patients receiving chemotherapy, and Patel suggested that an OCM 2.0 program could increase flexibility in treatment and could help address some of the challenges and complexities surrounding drug reimbursement. One such complexity is balancing patient access to novel agents in the pipeline while limiting inappropriate use of unnecessary and excessively expensive novel therapeutics.

OCM 2.0 would create an universal payment system that includes both drugs and services, and would focus on the patient at the point of diagnosis. These approaches, however, come at a time of extreme uncertainty in the legislative battles over healthcare reform, though according to Patel, the current administration supports the continuation of the OCM.

Patel emphasized appropriately addressing risk adjustment in claims-based data in the conceptual framework for OCM. She lamented the “crude” claims data currently used and expressed hope that staging data could improve risk adjustment.

“There has been this long-standing notion that community-based doctors are at odds with the larger tertiary and quaternary care institutions. That’s not true at all,” said Patel. She explained that offering high quality care in the community care setting is “vitally important” for the healthcare system and can limit costs.

Because of that, important elements for OCM 2.0 include flexibility for providers and for payers such that either can modify the model based on needs.

OCM 2.0 builds on a prevalent theme of improved transparency and emphasizes consensus among cancer care stakeholders, with clarity in expectations, simplicity to accentuate care, and decreased data collection. Transparency includes clear explanations of statistical methods of payment models.

Feedback on OCM 2.0 would emphasize on the need for ongoing certification, such as QOPI, NCQA, and COC. These certifications could be selected to align with the types of patients seen at a practice. Accountability for quality measures would mean practices need to demonstrate improvements in clinical performance.

Patel described unanimous agreement in tying drugs to value, and that innovation in value-based drugs for specific types of cancer holds promise. This may suggest that value-based drugs might not be feasible across all of oncology but could be applied in specific areas of cancer.

A basic payment model in OCM 2.0 might couple a fee-for-care coordination with opportunity for performance-based payment to create shared savings.

According to Patel, the majority of the country still uses one-sided risk, which is upside risk. If the entire country stays in one-sided risk, then the healthcare system will not move toward value. Patel encouraged the audience to consider what would motivate taking on downside risk to enter a two-sided risk model and move toward value.

Eventually, moving toward taking responsibility for the oncology population receiving care will need to address what costs are incorporated in a model, including total cost of care. If risk adjustment is accomplished appropriately, a model could incorporate total cost of care. Until risk adjustment is refined, however, a model should only include cost of cancer care rather than total cost.

To address risk adjustment, many practices use advanced electronics medical records, though issues remain in understanding how much and what kind of data are needed. “Something that Ted [Okon] and the co-leadership are actively trying to understand is what is the level of resource allocation it takes to start in one of these value-based models. That’s not trivial. The ACO literature supports that it can be anywhere from 5 million to 20 million dollars for an infrastructure investment,” explained Patel.

Another issue affecting risk adjustment is whether a patient participates in clinical trials. Community oncologists push to make sure that patients can access clinical trials, though there are particular challenges that arise in how to code a cancer patient who is receiving a therapeutic that might not have an NCT classification assigned. Otherwise, the system incentivizes not participating in clinical trials.

Cost target concerns continue to be an important issue. Cancer-related costs are the source and target for savings and benchmarking. Costs outside of cancer are more likely to be addressed once there is a better understanding of how oncologists can help control cancer costs. Addressing cost target concerns raises additional issues with unintended consequences. For example, uncertainty exists around how long payers might be willing to engage in a cost target contract.

Additional issues remain around drugs. The guidance in prescriptions that physicians will be expected to follow could rely on various pathways and guidelines, such as the NCCN guidelines, raising the question of what constitutes adherence to evidence. Additionally, if some guidelines are not included, that should be, a mechanism needs to exist to enable inclusion.

Payment needs to account for inappropriate prescriptions, which includes both over- and under-prescribing treatments. Patel suggested that the OCM 2.0 could use technology to remove barriers for prescribing the best, state-of-the-art therapies, as oncology cannot wait decades for an accumulation of sufficient evidence before implementing these therapies.

In addressing who is responsible for increasing costs, Patel suggested that maybe we are not spending enough money. Financial resources might not be utilized in the ICU setting, but perhaps care would improve if patients went to weekly appointments. She suggested that increasing reliance on patients to pay for the increasing costs in oncology is not sustainable.

In the need for OCM to be patient-centered, determining how to measure patient satisfaction and assessing the impact of what patients want could affect the model. Patel also encouraged consideration of whether there should be an active enrollment process for OCM to potentially encourage more proactive, engaged patients.

Importantly, feedback from healthcare providers emphasized not making the data entry and bureaucracy overwhelm the benefits of being in the model. Providers expressed a desire that tasks that are not directly patient-facing still align with patient-centered goals.

Patel concluded by emphasizing the importance of receiving feedback and the importance of creating value-based over volume-based systems.

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