Report Calls for Adding Shared Decision Making to CMS' Oncology Care Model

A new report published by the Urban Institute suggests that CMS’ Oncology Care Model (OCM) could be substantially improved by incorporating a formal framework for shared decision making (SDM) between patients and oncologists.

The report, funded by the Robert Wood Johnson Foundation, explores the history of the OCM, a 5-year pilot program that began in 2016 and aims to shift away from a strictly fee-for-service model towards a value-based paradigm of providing cancer care. The authors explain that the principles and guidelines that gave rise to the OCM’s creation recommend SDM efforts, but CMS did not require such processes when it released the final rule. They argue that amending the policy to incorporate SDM principles could improve the patient experience and potentially avoid inappropriate treatments at the end of life (EOL).

According to the report, the OCM was deemed a patient-centered care model by CMS when it was launched because it incorporated elements like care coordination and emotional support services. Practices are required to discuss treatment goals with patients, but are not obligated to follow a formal SDM framework beyond these discussions.

Support for SDM can be traced back to at least 1999, when the Institutes of Medicine (IOM) said patient preferences were “central to high quality cancer care.” Subsequent IOM publications, including the 2013 report that served as a foundation for the OCM’s development, continued to emphasize the need for SDM and patient-centered communication. CMS indicated when it invited oncology practices to participate in the OCM that the model would require SDM to inform treatment recommendations, but the actual program did not include that mandate when it went into effect in 2016.

To highlight the need for SDM, the Urban Institute report cited several studies that indicated cancer patients may not have the knowledge and opportunities to make decisions about their care. For instance, only 1 in 6 patients with metastatic cancers were able to correctly describe their prognosis, which may have been why many of them had undergone aggressive treatments like chemotherapy near EOL. Proper incorporation of SDM “could guard against chemotherapy overuse or underuse” and “also may address social disparities” by allowing patients to take a more empowered role in their experience with cancer.

From a policy perspective, the report authors argued that SDM is key to achieving value-based cancer care by improving patient satisfaction, even though there is not yet sufficient evidence to demonstrate that eliminating overuse of services through this framework results in cost savings.

“These findings underscore an important distinction between moral values, which concern patient autonomy and peace of mind, and economic value, which concerns dollars and cents,” they wrote.

They explained that the OCM mainly focuses on the economic components of value, but CMS has shown support for incorporating SDM in other initiatives. For instance, the Shared Decision Making Model will assess the impact of a SDM process on outcomes, spending, and patient satisfaction in accountable care organizations.

As such, the authors recommended that SDM should be incorporated into the OCM for certain cancers or at certain practices before the model ends in 2021. They noted that SDM could bring the OCM into alignment with the patient-centered values prominent in other CMS and HHS policies and documents.

“A large body of research indicates that many of the 1.7 million Americans diagnosed with cancer every year would greatly value more information-rich conversations with their doctors,” the report concluded. “Whether or not that desire for greater control over life-and-death decisions saves money for third-party payers, the implementation of shared decision-making shouldn’t require a moonshot-level effort.”