End of OCM Brings Drop-Off in Value-Based Care Volume, and New Questions

The end of the Oncology Care Model (OCM) and the financial incentives that came with it have led to significant drops in the volume of care conducted under value-based designs, according to oncology network and practice leaders who offered an update Thursday.

The change raises important questions about how to deliver care equitably when the revenue picture has shifted so sharply, which the group weighed during the discussion, “Defining Value in Oncology: Executing VBC Accurately & Ethically to Account for all Stakeholders,” during the Community Oncology Alliance (COA) Community Oncology Conference in Orlando, Florida.

Stephen "Fred" Divers, MD | Image credit: AON

Led by Stephen “Fred” Divers, MD, of Genesis Cancer & Blood Institute, who is chief medical officer of American Oncology Network, the panel also featured:

• Barry Russo, MBA, who is CEO of the Center for Cancer and Blood Disorders
• Donny Wade, MD, of the Virginia Cancer Institute
• Lalan Wilfong, MD, of Texas Oncology and senior vice president, The US Oncology Network.

When Divers asked how much the share of practice volume in value-based care had dropped since the end of the OCM, the percentages varied, but Russo estimated the shift had been 70% to about 30%.

In addition, the arrangements that remain are largely bonus-type arrangements or upside risk only; for practices that did not sign on for the Enhancing Oncology Model (EOM), downside risk models are harder to find.

During the OCM, practices were required to extend new services to patients, such as patient navigation and advanced care planning, that improved patients’ experience and also helped achieve savings. Most practices opted to extend these services to all patients, because, as Wilfong said, “it’s the right thing to do.”

“I wish I new I knew the secret sauce “ he said. Economics have shifted from the days when drug margin compression was the main issue. Today, before you extend services to patients outside a reimbursement model, “you really have to think through that as a practice when you get into risk-bearing entities,” he said. “Your economics change quite a bit [in] how you practice medicine.”

Comparatively few practices signed on for Medicare’s EOM because the financial package was seen as unpalatable and because the program did not allow practices a test period of upside risk only, as had been the case with the OCM. Since the launch of the EOM on July 1, 2023, CMS has initiated a rule that allows practices to separately bill for patient navigation—even for practices not inside the EOM—which could make the bottom line more attractive. However, CMS would have to reopen the model for it to expand beyond the 44 that initially signed up.

Russo discussed how relationships with primary care providers are increasingly important in cancer care—not only for referrals, but also in establishing better continuity of care that is better for patients and helps hold down costs. “That's becoming a much larger piece of our value-based world,” he said.

Working with primary care. Many oncology practices may have formal or informal relationships with primary care providers in capitated payment models with payers, Russo said; these physicians are now keenly interested in keeping patients out of the hospital.

Divers asked whether data are keeping up with the task, and Russo said this is a concern. He said he’d met with a primary care practice that he thought would be get data back within 30 days, and learned it was closer to 90 days. “The problem with that is, is that if you want to change behavior, you can't,” Russo said. “It's too late.”

Like Russo’s practice, Wade’s practice took part in OCM but did not move forward into EOM. In the OCM, Virginia Cancer Institute brought services such as dietitians and care managers in house and began practices that have proved valuable. “It’s just so important to be able to reach out to your patients at least once a week or so to check and see how they're doing, to make sure that you're doing everything you can to keep them out of the or keep them out of the hospital,” he said.

Both Wade and Russo have had PCPs ask questions about the level of care for patients with hard-to-treat cancers. Thus far, Wade’s relationships with PCPs are informal; he deals with physicians 1-on-1 and is not in any capitated relationships. In Russo’s practice, some of the relationships are more evolved; he got a call from a primary care practice wanting to know why a patient had an extended hospital stay. “He has acute leukemia,” Russo said.

Divers agreed that working with primary care has its pros and cons, as primary care providers may need education to understand what levels of care might be needed in oncology—and when it might be necessarily expensive. “Part of a risk bearing entity here is [we] have to be a good steward of the dollar, but we got to keep that patient first,” Divers said. “So, what guardrails do you put in place when you start to set up these guidelines discussion?

“That’s something we struggle with all the time,” Wilfong said. He said almost every oncologist can point to an example of a patient who was treated to long and a case where a patient did not receive the level of care needed.

“What is that balance?

The panelists discussed how possible AI solutions could help, but this comes at a cost. Both Russo and Wilfong described the number of people it takes to care for cancer patients correctly, the investment it takes, and how revenue streams don’t always align with the costs.

“It takes a village to take care of a cancer patient,” Russo said. “That village is not just the people in your organization—it’s a lot of people outside your organization,” which can include foundations or insurance brokers who can help fill gaps for patients who need to get on the right coverage plan.

“If they're not in your village now, you need to start building your village because it's essential to make this thing work for your patients in your practice.”