Oncology practices that adopt the OCM developed by the CMS face a tough road. The transformation requires changes in infrastructure encompassing administrative and care management service lines, as well as a change in philosophical outlook for clinicians and physician leadership; translational services for clinical interpretation; and internal reporting that is both costly and complex.
Oncology practices that adopt the Oncology Care Model (OCM) developed by the Centers for Medicare & Medicaid Services (CMS) face a tough road. The transformation requires changes in infrastructure encompassing administrative and care management service lines, as well as a change in philosophical outlook for clinicians and physician leadership; translational services for clinical interpretation; and internal reporting that is both costly and complex. But those practices that take on this change, although experiencing initial growing pains, are finding benefit as efficient care management strategies are implemented, emergency department and inpatient utilization resources are reduced, and successful reporting for staging and quality is rewarded, Lucio N. Gordan, MD, said during the Association of Community Cancer Centers 45th Annual Meeting & Cancer Center Business Summit in Washington, DC.1 He recounted this experience as Florida Cancer Specialists & Research Institute (FCS) made the change.
The transition from a fee-for-service model to a value-based model required a complete practice transformation. The physician buy-in and cultural shift was a challenge, said Gordan, managing physician and president of FCS. No sugar coating was necessary. As far as educating our physicians, that was painful.
Gordan could understand the physicians frustration. Who wants to be clicking your life away on an electronic medical record?
FCS adopted the OCM in the fourth quarter of 2016. The group practice comprises 98 clinical sites, more than 450 providers, and over 3500 team members, and treats 1.5 million returning patients. There were no value-based care contracts in 2015, but currently, 62% of the practices contracts are value based. What early benefits has the practice seen as a result?
We are in the black, Gordan said, when looking back over performance period 3 (from October 2016-September 2017). Our metrics indicate our hospital admissions rates were 8.5% lower than our peers, [and] we had 29% less emergency department visits compared with OCM peers and 41% less than non-OCM peers. In addition, inpatient admission to short-term acute care was reduced by 19% and unplanned hospital admissions were down 17% (see FIGURES 11, 21, and 31). Not only were utilization metrics down, he said, but the practice also had an overall patient rating of 9.02 out of 10, with an aggregate quality score of 84% on claim, survey, and patient self-reported measures such as pain, depression, and patient satisfaction.
Gordan emphasized the effort that the practice has made to launch and integrate their care management service line. The service is delivered by 100 staff members, including oncology nurse care managers, nurse triage experts to address potential emergency issues and boasts a patient satisfaction score of 96%. Not only do case managers interact and share information with all participants in the healthcare process, but patients also gain a nursing advocate who can provide emotional support. Physicians and hospitals have complex cases coordinated and facilitated, and payors see a reduction in costs.
Looking ahead, Gordan would like to see some changes in the OCM, including better pricing models for high-risk patients, exclusion of patients with very expensive underlying diseases (eg, sickle cell or hemophilia) or patients who undergo transplantation, real-time notifications to the healthcare team if the patient experiences acute emergencies to enhance closer monitoring, faster access to claims data, and novel therapy adjustments.
The OCM was developed by CMS as an episode payment model to encourage providers in group practices to provide higher-quality, better-coordinated oncology care at a lower cost. It requires group practices to provide a set of enhanced services during 6-month episodes of care. Further, OCM includes a per-beneficiary, per-month payment of $160 for the provision of enhanced services, called a monthly enhanced oncology services payment. There are also opportunities for the group to receive performance-based payments on the basis of reductions in actual expenditures for the practices beneficiaries compared against risk-adjusted episode target prices and the practices performance on quality measures.2
Charles Saunders, MD, CEO of Integra Connect, a company that provides technology and services in support of oncology practices who have adopted the OCM and copresenter during the session, shared the results of a survey of oncologists and their views on the OCM.
Overall, community oncologists are optimistic about value-based care, Saunders said. As a result of OCM adoption, oncologists are changing treatment decisions, especially when it comes to drug choices, added Saunders. About 38% of oncologists surveyed are opting for lower cost therapies; still others are seeking a deeper understanding of drug value.
Saunders said that regimen selection is based on National Comprehensive Cancer Network guidelines, but there has not been an abundance of actual real data that look at the totality of medical claims. The OCM provides that now. With this capability, to link claims history with outcomes, oncologists can understand the differences between regimens and choose better regimens over others.
Saunders said that there has been a lot of criticism of the OCM program. the attribution logic and the high cost of collecting and reporting data are challenges. Despite these difficulties, I suspect, though, that value-based care in oncology is here to stay, Saunders said.