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Practice Matters

News from Lola Butcher about health policy and practice management issues of importance to oncologists

Wednesday, February 18, 2015

What Oncologists Think about the Oncology Care Model

While waiting for tomorrow’s webinar from the Centers for Medicare and Medicaid Innovation Center (12 noon Eastern) introducing CMS’s Oncology Care Model (OCM) as a new way to pay for cancer care, I asked several people I respect to share their initial impressions. 


Oncology practices participating in the new plan will receive a $160 per-patient per-month payment and the opportunity to receive performance bonuses on top of Medicare fee-for-service rates. In return, they must provide high-value services including patient navigation, care planning, 24/7 patient access to a clinician, and the use of data for continuous quality improvement. Check out this fact sheet and these FAQs for details known as of today.


CMS intends to launch the plan in 2016, starting with practices that, through an application process, convince CMS they can meet the requirements. Oncology practices that wish to apply must submit letters of interest by April 23; applications are due by June18.


We will all be learning more about this new pay program in the weeks and months ahead, but here are first thoughts:


 Al B. Benson III, MD, Associate Director for Clinical Investigations, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago:  “I would agree with the American Society of Clinical Oncology that this is a fee-for-service model and that what is needed are more innovative approaches to address comprehensive cancer care delivery that best meets the needs of individual patients. ASCO has suggested some alternative models. 


“It is commendable that OCM is employing the IOM Care Management Plan and that treatment should conform to that recommended in national clinical guidelines. One would hope that a financial incentive model will not compromise clinician-patient choice of appropriate therapies and that patients will be fully informed as to treatments based on recognized guidelines. Models such as these should work to assess patient-reported outcomes and ascertain what services are critical to an individual’s overall cancer care incorporating an extensive range of services such as dietary intervention, genetic counseling, financial services, psychosocial support services, home care, and transportation as some important examples.


“Any economic or reimbursement model would need to have the flexibility to adjust for the variability of services, extending beyond drug treatment, reflecting the needs of each individual, and the out-of-pocket costs incurred by the patient. Encouraging patient participation in clinical trials should be an essential component of any model as well as reduction in administrative burdens, which increasingly are both costly and eroding the office time that would be best spent on the actual delivery of care to patients.


“In addition, the OCM model focuses on the physician office setting. While important, there is a growing trend to deliver cancer care in the hospital outpatient department – a trend that deserves attention for multiple reasons including possible limitations to access because of travel, increasing cost of care in the hospital versus the office setting and whether the ability to deliver high-value, quality care that is comprehensive can be improved in the hospital setting.”


 Barry Brooks, MD, Chair, US Oncology Pharmacy and Therapeutics Committee, and partner, Texas Oncology, Dallas:  Briefly, I think the per-patient management fee of $160/month is on the modest side for the case-management effort required, but candidly, it is more than I thought we might be offered. Benchmarking a US Oncology practice against itself for performance payment seems to punish us for our parsimony and stewardship over the last eight to nine years of clinical pathway development. We practice a disciplined, evidence-based form of oncology that is very cost-effective and we do not have as much room to shave costs as practices that have not yet embraced pathways. These latter practices could decrease their oncology spend by a much larger percent than we can because they have not harvested the “low-hanging fruit” available through clinical pathways and focusing on avoiding hospital admissions and ER visits.


“Another concern I have is that there is no mechanism to deal with costly immuno-oncology and targeted drugs that are currently flooding the market. Cancer care is going to be very expensive in the next three years -- more effective, but much more expensive. If CMS were to measure the cost of our treatment of lung cancer in 2014 versus that of treating the same patient in 2016, the cost could be up to 10 times greater even in a strict evidence-based world because of the costs associated with drugs like nivolumab.


“Bottom line is we are very excited to potentially be able to pilot our Innovent oncology model in a CMS project, but I fear that there can be no realistic expectation that anyone can achieve performance payments unless the model is adjusted for some of the factors mentioned above.”


 Patrick Cobb, MD, an oncologist/hematologist at St. Vincent Frontier Cancer Center in Billings, MT:  “I think it’s good that CMS is recognizing the value of multiple services that oncologists have provided to our patients, services that have not been reimbursed in the past.


“Most oncologists already provide most of the services in the list, so I don’t think it will be difficult for practices to participate. Usually problems arise when it’s time to report the data, and I hope CMS will make that process easy.


“Provider-based practices like ours that are aligned with a hospital can’t participate in this program, and that excludes a large portion of the cancer delivery system.


“I’m a bit skeptical that this program will decrease the overall costs of caring for cancer patients.  I think we can save some money by trying to keep patients out of the emergency room or the hospital, but progress in cancer treatment often includes adding newer drugs that are usually very expensive. Oncologists have no control over what pharmaceutical companies charge for these new agents.”


 Kathy Lokay, President and CEO, Via Oncology:

   “I really like the $160 per patient per month during each six-month episode and that CMS didn’t cap it at two episodes.

    “I’m concerned, though, about the volume and types of quality reporting measures (total cost of care and patient share of it, prognosis/expected response to treatment, lots of self-reported measures that today are only samples for Quality Oncology Practice Initiative purposes). Will they set quality targets or expect x% year-over-year improvement? Also, I will want to see how the gainshare would be reduced if you didn’t hit your quality measures.

    "Finally, lots and lots of questions remain about how the targets will be set and updated--the devil’s in the details here! And how do you stop folks from withholding certain care because it’s too expensive for their target? It’s hard to attest care concordant with guidelines when you don’t have a service to attest to (e.g., no neoadjuvant therapy to avoid including surgery costs; no radiation for bone mets, etc.).”


 Neal J. Meropol, MD, Chief, Division of Hematology and Oncology, University Hospitals Case Medical Center & Case Western Reserve University, Cleveland: “The time is ripe for payment reforms that reward coordination of care and better align financial incentives with high quality care and patient outcomes. The CMS program is an initial step in the right direction, but there is a long way to go to optimize how we pay for oncology care in the United States.”


 Lawrence Shulman, MD, Chief of Staff, Senior VP for Medical Affairs and Director, Center for Global Cancer Medicine, Dana-Farber Cancer Institute, Boston:  “In theory this is a good idea. I think we need to get to accepted pathways for disease treatment, but this might be a good first step.”



 Mark A. Sitarik, MD, Medical Director, Technology, McKesson Specialty Health, and partner, Rocky Mountain Cancer Centers, Boulder: “I think the concept is a good starting place. The proverbial devil will be in the details:

    Will the incentive payments be adequate to offset the added reporting requirements?

    How much of the reporting can be automated?

    What will the criteria be used to decide if a good episode of care was delivered?

    How many of those criteria will actually be under my control?

    What does payment after the episode mean? A week? A month? A year? After an audit?

“I think in general oncologists want to be reimbursed for the intellectual work that they do. I applaud CMS’ step in this direction. The challenge will be to implement this paradigm shift in a way that will not break the ability of providers to deliver care to our patients in need.


“I suspect that it will require climbing up and sliding down the learning curve a few times for all of the stakeholders before a functional system is fully developed and implemented. It will likely require a great deal of flexibility on the part of all parties involved.”