Feedback on the Direction, Challenges of the OCM

The Oncology Care Model (OCM), CMS' bundled payment program for oncology, is a 5-year model that began 2 years ago, and early experiences have revealed areas for improvement, as well as just how hard it can be for practices to perform well. During a webcast, Bruce Feinberg, DO, of Cardinal Specialty Solutions, moderated a conversation with Bruce Gould, MD, of Northwest Georgia Oncology Centers (NGOC), and Mark Liu, of Mount Sinai Health System, regarding the implications of feedback to the model, so far.

This discussion was part of The American Journal of Managed Care^®’s OCM webcast series. You can watch the full discussion here or other discussions in the series here.

Most practices participating in the OCM are sophisticated practices that deliver quality care and have prior experience with alternative payment models. Gould’s practice has had years of practice already after having participated in both UnitedHealthcare’s episodes of care program and the COME HOME program, developed by Barbara McAneny, MD, and Innovative Oncology Business Solutions.

Participating in both of these programs prior to the OCM provided NGOC the confidence that it could meet many of the practice transformations that were a requirement for OCM participation. However, Liu noted that Mount Sinai spent a lot of time the first year on building the infrastructure and educating employees to get in the right mindset.

While NGOC might have had the infrastructure mostly in place, it did struggle, like most other participating practices, with the “onerous” reporting requirements, Gould said. The practice also had difficulties compiling the Institute of Medicine (IOM)’s 13-point care plan, which is mandatory for all participants in the OCM.

“A lot of the information that’s required for that 13-point IOM plan is not in the [electronic medical record] where we can push a button and just have it spit out,” he explained.

Liu echoed the challenges Gould faced at NGOC and added that Sinai realized when it came time to presenting the information to CMS that most of it didn’t live in a structured field. As a result, Sinai took a look at the clinical documentation to see if it could redo how information was being captured in a way that didn’t greatly impact the care team.

Looking at the first results of the program, Feinberg noted that drug costs were higher among OCM participants than nonparticipants. Since the participating practices represent some of the most sophisticated in the country, he wondered if those higher drug costs come as a result of these practices being more up to date on the latest treatments and early adopters of them.

Gould agreed that the assessment was likely accurate. NGOC gets experience with newer drugs before they’re on the market, which means the practices are comfortable using them and adopt them “right out of the gate.”

The challenge is that newer therapies are increasingly more expensive, which can negatively affect practices trying to meet a target price. For example, during 2012 to 2015, a patient diagnosed with breast cancer and placed on aromatase inhibitors had relatively low costs. The episode was priced at about $5000 for 6 months, Gould said. But, now, there are CDK4/6 inhibitors, which nearly double progression-free survival but are priced at roughly $50,000 for 6 months.

“And that, of course, blows away the target price,” he said.

While there is a novel therapy adjustment, Liu said Sinai expected that CMS would provide more of an adjustment than it actually did. It was hoping that the adjustment would offset the vast majority of the amount it was over the target price, but that ended up not being the case.

Both Liu and Gould admitted that their practices were in the red as of the first reconciliation reports that were released in February. Gould said the challenge was that NGOC was being compared against itself, so the bar was a lot higher.

“We’ve got probably the most sophisticated practice in the country with the most experience doing this work [in the red], which is fascinating and scary at the same time,” Feinberg said.

Both Liu and Gould agreed that even if there are aspects of the OCM that they would still like to see changed and adjusted, the direction it is headed in is right. “Value-based care is here to stay,” Liu said, and the OCM has allowed practices of all shapes and sizes to work together.

Gould added that he has been glad to see CMS get into the value-based care arena. NGOC and other practices participating in the OCM are working hard to provide feedback to improve the program and make it sustainable.

“At the end of the day, I think it’s imperative upon physicians to really not only use good clinical judgement but be good financial stewards of the healthcare dollar so that we’re able to afford these new expensive treatments,” Gould said.