Oncology Care First Model Draws Criticism From Stakeholders
In early November 2019 the Centers for Medicare & Medicaid Services and the Center for Medicare and Medicaid Innovation 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. Since then, oncology stakeholders have been weighing in with recommendations and criticisms.
The American Society of Clinical Oncology encouraged CMS to consider an alternative to its total cost-of-care methodology, which holds physicians responsible for the list price of drugs. ASCO said it believes that physicians should instead be held accountable for the utilization of services, including drugs, through targeted cost and utilization measures that protect against potential stinting of care.
ASCO also recommended that the agency adopt the society’s recently updated Patient-Centered Oncology Payment (PCOP) model.
PCOP uses three major approaches: improved care delivery and coordination through an oncology medical home framework, which has shown improved outcomes and reduced costs; a performance-based reimbursement system that relies on patient-centered standards and transitions to bundled payments; and consistent delivery of high-quality care using clinical pathways that adhere to ASCO criteria. ASCO’s data show significant potential for PCOP to yield cost savings—up to 8 percent across the healthcare system—with a model that accommodates diverse practices and care settings and guides participants through its implementation.
“Through the framework laid out in the PCOP model, we believe CMS can achieve its goal of a truly multi-payer model that improves care delivery and reduces costs,” said ASCO President Howard A. "Skip" Burris, III, M.D., in the comments. “We encourage CMS to adopt this model also, either under CMMI or through waiver authority to local contractors.”
Failing to correct flaws of Oncology Care Model
Harold D. Miller, president and CEO of the Center for Healthcare Quality and Payment Reform (CHQPR), a national policy center that facilitates improvements in healthcare payment and delivery systems, published a 55-page report, noting that the Oncology Care First draft fails to correct most of what he calls the serious problems with the current Oncology Care Model. “It includes several new features, some aspects of which are positive but others have the potential to create additional problems beyond those that exist under OCM,” he wrote.
Miller, who also serves as adjunct professor of Public Policy and Management at Carnegie Mellon University, says the model’s Performance-Based Payment component, would “calculate bonuses and penalties using a methodology almost identical to the problematic approach used in the Oncology Care Model. As a result, just like the Oncology Care Model:
• OCF would reward oncology practices for withholding needed treatments;
• OCF would reward oncology practices for delays in completing treatments;
• OCF would penalize oncology practices for using evidence-based care; and
• OCF would encourage oncology practices to avoid treating patients who need more expensive treatments and who have health problems unrelated to cancer treatment.”
“It is surprising and disappointing that Oncology Care First fails to correct most of the serious problems with the Oncology Care Model. The problems with the Oncology Care Model have been known since the time the OCM design was first announced,” Miller wrote, “and practicing oncologists have regularly provided CMS with both examples of the specific problems OCM has caused for practices and patients and specific recommendations on how to fix the problems. In the materials describing Oncology Care First, however, there is no indication that CMS has even tried to solve the problems or is interested in making the changes needed to do so.”
Last November, Miller was one of two members to resign from the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which was set up in 2015 to provide recommendations to the Health and Human Services (HHS) Secretary about new alternative payment models. In resigning, Miller none of its 16 recommendations has been approved.
Community Oncology Alliance calls timeline ‘completely unrealistic’
The Community Oncology Alliance, a nonprofit organization dedicated to independent community oncology practices, 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.”
Recommendations to strengthen patient navigation
In a joint letter to CMS, the Academy of Oncology Nurse & Patient Navigators (AONN+) and the National Navigation Roundtable (NNRT) commended the potential of the OCF model, but shared concerns with regard to the quality and consistency expected from patient navigators.
In their response, AONN+ and NNRT call upon the Innovation Center to consider changes to the OCF model that would strengthen patient navigation including:
• Providing comprehensive information about patient navigation to physician group practices and eventual participants, including the process for identifying patients in need of navigation, the identification of logistical barriers and social needs, and the ability to track patients throughout their care
• Encouraging physician group practices to designate patient navigators on staff and identify appropriate community partners to assist with services and resources beyond the scope of the enhanced services offered
• More closely evaluating how physician group practices implement the patient navigation process and hold practices accountable for this requirement through its evaluation process
• Working with patient navigation stakeholders to provide physician group practices with ongoing resources to improve the quality of navigation services offered.
