Lessons Learned from the Oncology Care Model Transforming Care or Checking the Box? Barbara L. McAneny, MD Gabrielle Roque, MD Kerin Adelson, MD
The Oncology Care Model (OCM) Patient population: The CMMI Payment Model applies to all patients with new chemo start Episode definition: 6 months following new chemotherapy start, repeatable Payments OCM pays physicians in three ways: -- Normal FFS Payment -- $160 PBPM (per beneficiary per month) -- Shared Savings/Risk Sharing Episode Price/Discount to Medicare: -- 4% discount for shared savings -- 2.75% discount for accepting full risk 2
The Come Home Model
CMS/CMMI Grant $19.8M 7 practices Significant savings associated with Oncology Medical Home through reduced ED & IP use Improve quality of care through triage protocols, team care and clinical pathways Increase delivery of patient-centered care through after hours clinics, same day appointments, patient education and patient portal 4
Summary of Findings NMCC Post-COME HOME compared with NMCC in the Pre-COME HOME period: 35.9% drop in % of patients with ED Visits 43.1% drop in % of patients with IP Admissions 23.8% drop in inpatient days $4,784.08 (22.4%) drop in six month total cost of care NMCC Post-COME HOME compared with contemporaneous data from the Albuquerque MSA: COME HOME patients are 50.2% as likely to have an ED Visit COME HOME patients are 43.6% as likely to have an IP Admission COME HOME patients spend 2.71 fewer days in the hospital COME HOME patients cost Medicare $2,149.28 (11.5%) less 5
OCM: What s Working and Not Working? 6
What s Good About the OCM Large, flexible MEOS Payment Billed by the practice each month using a G-code Larger than current care management payments or in primary care medical homes Not tied to face-to-face visits with clinicians or specific procedures Opportunity for higher payment for an oncology practice that avoids complications, reduces unnecessary use of testing, reduces unnecessary use of expensive medications, etc. 50% of patients on chemotherapy may end up in the ED or hospital due to complications (e.g., dehydration from nausea/diarrhea, fever) of chemotherapy; most ED visits can be avoided by office-based interventions Many patients receive unnecessary lab testing and imaging Many patients receive expensive white cell stimulating factors while on chemo regions with low risk of neutropenia
What s Problematic About the OCM, Part 1 CMS administrative requirements to participate in OCM increase practice costs, offsetting additional revenues from monthly MEOS payments 24/7 patient access Care coordination Quality and clinical data reporting (which EHRs don t support) MEOS payment is triggered by chemotherapy No explicit support for diagnosis and treatment planning Implicit penalty if patients decide not to start or continue chemo MEOS payment is the same for every patient Disadvantages practices with patients who have more complex cancers, worse functional status, poor caregiving support at home MEOS payments can be recouped based on FFS attribution Troublesome precedent to have CMS recoup a fee billed by a physician because CMS determines the patient belonged to a different practice
What s Problematic About the OCM, Part 2 Savings based on total spending, including services for conditions unrelated to cancer that the oncologist can t control The risk adjustment model used to determine expected spending fails to include some of the most important factors that affect spending on patients, such as the stage of cancer CMS recognizes the need for these data and is requiring the practices to submit the data, but the practices incur the admin. costs In the meantime, performance-based payments are calculated using the problematic methodology Variation among patients creates potential for unfair penalties or windfall bonuses based on patient mix rather than practice performance Cancer treatment doesn t neatly fit into 6 month episodes; average spending looks lower if chemo treatments are delayed
What s Problematic About the OCM, Part 3 Most savings opportunities are in avoidable ED visits and hospitalizations, but most spending goes to drugs Spending changes due to new drugs, new evidence about drug effectiveness, price increases, etc. can dwarf the savings achieved by the oncology practice There is no change in the way the oncology practice is paid for drugs, so if a lower cost drug can be used, the practice loses revenue associated with that drug but may or may not get a performance-based payment Moreover, many of the drugs that are cheaper for CMS have payments to the practice that are below its acquisition costs The OCM spending measure only includes the portion of Part D that is not paid by health plans, so putting a patient on an oral drug, even if it s more expensive, may achieve savings for CMS, but not a reduction in true total spending, while also reducing the practice s margins on infused drugs
What s Problematic About the OCM, Part 4: Target Calculation 16K historical episode data (2012-2015) from CMS Residual Value : OCM model predicted value - actual values for each historical episode Residual Plot: Scatter Plot of Residual vs Predicted Value If the points are not randomly dispersed across the red line, than a linear regression model is inappropriate. R-squared =0.334 Time and Clinical data are not included in the model -> Residual plot not randomly dispersed around the red line. 11
OCM risk arrangements One-Sided Risk Arrangement 4% OCM Discount Practices not responsible for repaying Medicare for expenditures exceeding Target Amount All practices are currently in one-sided risk Two-Sided Risk Arrangement 2.75% OCM Discount Practices must repay Medicare expenditures exceeding Target Amount (up to 20% of Benchmark) 12
Simulated PBPs OCM Full Risk 13