Abstract: The Oncology Care Model has reached yet another major milestone, releasing its year-three results in August 2019. Though participants have shared concerns over potential weaknesses in the program, like attribution logic and novel therapy adjustment, the almost 1000 provider participants working with Integra Connect continue to find value-based cancer care an inevitable necessity as more commercial payers adopt value-based models. Looking at performance data available to date and projected expected performance for performance period (PP) 8 with respect to one-sided vs two-sided risk, approximately 50% of practices will likely benefit from the two-sided model. With lessons learned from the PP1-PP4 results, the three most determinant critical success factors for optimizing continued performance improvement are expected to be application of predictive analysis of end-of-life decisions and of care pathway effectiveness (including drug selection); investment in key technologies for care coordination and performance trend analyses; and risk mitigation strategies such as post-attribution billing and stop-loss insurance.
The Oncology Care Model (OCM) has now been in full swing for more than 3 years. Integra Connect is a health IT company that helps specialists succeed under value-based care and works with a large cohort of OCM providers and patients nationwide, ie, approximately 10% of participating practices representing approximately 1000 providers. Throughout these past 3 years, Integra Connect has been working closely alongside practice clients, gaining invaluable insights into their wins and losses along the way.
This article utilizes proprietary data collected via Integra Connect’s population health and predictive analytics tools to comment on and contextualize the success of OCM to date.1 These tools gather information to support value-based care by analyzing payer claims data including chemotherapy, radiation, imaging practice patterns, drug cost comparisons, and risk profiles.
Contextualizing OCM Performance Data
While Performance Period (PP) 1 and PP2 revealed significant challenges, when the OCM PP3 results were released in late-February 2019, the overall sentiment was optimistic. Validating beneficiary eligibility was a recurring challenge, resulting in unbudgeted monthly enhanced oncology services (MEOS) recoupment, and OCM participants continued to struggle with comprehensive coding for patients with comorbidities. However, total-costs-of-care trends continued to improve, resulting in an increasing number of performance-based bonus recipients, including 40% of Integra Connect’s OCM clients.
While these positive cost trends fostered an aura of optimism on the cusp of the PP4 results reporting, actual performance results came as an unwelcome surprise. While 50% of Integra Connect’s clients saw a performance improvement, only 20% undercut their PP4 benchmark prices by 4% or more and, as a result, received a performance-based payment (PBP). Eighty percent of practices spent more than their PP4 target price, highlighting difficulties with the ever-moving target price and new cost pressures that surfaced during the PP4 reporting period.
More so than in prior years, drug selection directly impacted practice performance. Those practices that selected more expensive therapies were, on average, more likely to miss target price. Moreover, for community centers that serve as tertiary clinics for nearby health systems, patient populations tend to be sicker (ie, more comorbidities to manage), but insufficient hierarchical condition category (HCC) coding means these additional costs of care are not sufficiently accounted for in target price.
As costs associated with adverse events, such as emergency department visits and inpatient hospitalizations, are mitigated through enhanced patient engagement services, total drug spend comprises a larger and larger proportion of the total cost of care, accounting for nearly 60% of the total cost of care per episode, on average.1 While the Center for Medicare and Medicaid Innovation offers a novel therapy adjustment, Integra Connect’s analyses have uncovered that this tends to benefit only smaller practices, because the adjustment only applies when practices leverage novel therapies for a larger percent of their patient population than others in their peer group.
The Next Major Inflection Point for the OCM: Two-Sided Risk
Practices are now facing a key decision: should they assume two-sided risk or not? For those who have not yet received a PBP during the first 4 PPs, they must accept two-sided risk or exit the program altogether. The remaining participants may optionally assume two-sided risk—which reduces the savings hurdle from 4% to 2.5% and offers potential eligibility for a 5% Advanced APM bonus—or stay the course with the one-sided risk model. To support their decision making, Integra analyzed their OCM practices’ historical performance to provide them with projections of possible scenarios, gaining visibility into the best, worst, and most likely cases. This was achieved by first constructing a data set describing patients with episodes start dates in each calendar month, as well as characteristics describing comorbidities (HCCs) and case mix (by cancer type). The resulting data sets were then applied to a comprehensive set of predictive algorithms to identify which model most accurately predicted clinical and financial outcomes, and specifically projected performance for PP8 under the alternative two-sided risk arrangement.
The results were surprisingly variable. For some practices, their likelihood of achieving a performance-based bonus was greater than facing recoupment. Alternatively, other projections revealed that some practices had already optimized their cost performance and were unlikely to further reduce total costs of care relative to their target price. Overall, for practices who had achieved a performance-based payment in a prior period or were nearing cost targets, performance projections trended favorably, either falling between benchmark and target price or beating target price goals.
About half of Integra Connect’s clients who have not yet received a bonus through PP4 are considering remaining in the program and accepting two-sided risk. Most of these practices are close to breaking even under the one-sided model and anticipate meeting target cost reductions under the two-sided model, given the lower savings hurdle, by continuing operational improvements. Of practices who have received a PBP, only those who are significantly over performed on cost performance are considering moving to the two-sided risk model. Those who are electing to leave the OCM program have referenced beneficiary identification and program complexity as top reasons for their departure.
With this important financial shift on the horizon, we see three major focus areas to sustain continued performance improvement:
Application of predictive analytics to mitigate high-cost resource utilization and optimize drug decisions. After drug spend, resource use at the end of life continues to be a leading cost driver, and there remains opportunity to increase use of end-of-life programs, palliative, and hospice care. As one study (which was presented at the American Society of Clinical Oncology Annual Meeting in June 2019), showed, enrolling patients in hospice during the last 30 days of life reduced total costs of care during this period by 35%.2 By leveraging predictive models to identify patients’ risk at end of life, care teams will be empowered to refer more eligible patients to palliative care, resulting in better quality of life3 and reduction in total cost of care.
With the rise of novel therapies, oncologists are looking to compare a set of therapies and predict outcomes. By taking into consideration a patient’s specific diagnosis, stage, and other clinical factors, oncologists can apply predictive analytics to care pathways to project the efficacy, toxicity, and total estimated cost of care for each treatment option. These insights enable more informed drug decisions and help oncologists optimize their mix of biosimilar, generics, and novel therapies, supporting better clinical outcomes as well as meaningful drug cost reductions.
Investments in key technologies essential for managing continued performance improvement. Many practices who received a PBP prior to or during PP4 invested substantially in care coordination technology and services in order to keep patients out of the hospital, which contributed positively to total costs of care. While overall performance trends for Integra Connect’s cohort of clients have consistently improved from one period to the next, they are now exceeding Centers for Medicare & Medicaid Services’ (CMS) benchmarks by taking proactive steps to engage and manage their patient populations. To maintain this momentum, practices should continue to leverage high-tech and high-touch solutions to target high-risk patients and deliver care coordination.
These high performers are also investing in more sophisticated data and analytics solutions to gain a deeper understanding of their performance trends. Due to the inherent lag time between each actual PP and when practices get their results, these practices have invested in technology and tools that deliver real-time visibility, empowering their leaders to prioritize and optimize practice transformation efforts, as well as related investments.
Tools and solutions may include predictive analytics to stratify at-risk patients and ensure the highest risk cohorts are targeted for care coordination services; care management technology to monitor care between office visits; and advanced analytics using electronic health record and practice management system data to help prospectively identify OCM episodes and monitor drug utilization with a focus on cost-saving opportunities.
Risk mitigation efforts to stabilize and protect future cash flows. Through PP4, MEOS recoupment dollars remained steady even though MEOS revenue declined. This trend has been attributed to practices’ inability to recreate CMS attribution logic, especially for patients with multiple cancers and patients with multiple comorbidities who visited other providers more frequently. Moreover, to avoid unbudgeted MEOS recoupments, practices have been exercising more caution with MEOS billing, resulting in underbilling for eligible patients who were attributed to the respective practice, effectively leaving money on the table. To address this, leading practices have started taking a seemingly unorthodox approach, electing to bill all MEOS retrospectively, after the CMS releases the final list of MEOS-eligible patients for each PP. This approach has enabled these practices to mitigate MEOS censorship and reduce the risk of MEOS recoupment, increasing MEOS revenue overall.
Moreover, practices who have not yet received a PBP but who elect to transition to the two-sided risk model may benefit from stop-loss insurance, which provides protection against catastrophic or unpredictable losses. That said, before investing, it will be important to evaluate whether the insurance premiums plus deductible are cheaper or more expensive than the projected recoupment from CMS.
Conclusion
Irrespective of how many practices remain in the program in 2020, the OCM’s success to date has already delivered on its mission of driving higher quality, more coordinated cancer care at a lower cost to patients, making it the foundation against which all future programs will be measured. Moreover, a robust pipeline of new fee-for-value efforts—for example, the Community Oncology Alliance’s OCM 2.0 to the Making Accountable Sustainable Oncology Networks (MASON) program4,5—will ensure that value-based cancer care continues to thrive.
References
1. Sheth K. Integra Connect OCM Network Data [proprietary data]. Analysis completed September 23, 2019.
2. Akhtar AJ, Margolis J, Maxwell K, et al. A community oncology palliative program: early results for cost and quality measures within OCM program claims data. J Clin Oncol. 2019;37(suppl 15):11585-11585. doi:10.1200/JCO.2019.37.15_suppl.11585
3. Spettell CM, Rawlins WS, Krakauer R, et al. A comprehensive case management program to improve palliative care. J Palliat Med. 2009;12(9):827-832. doi:10.1089/jpm.2009.0089
4. Community Oncology Alliance. Community Oncology Alliance Announces “OCM 2.0” Proposal, an Ambitious Reform Model to Improve Cancer Care and Reduce Costs. communityoncology.org website. https://www.communityoncology.org/community-oncology-alliance-announces-ocm-2-0-proposal-an-ambitious-reform-model-to-improve-cancer-care-and-reduce-costs/. Published June 11, 2019. Accessed November 21, 2019.
5. America Society of Clinical Oncology. ASCO In Action: HHS Advisory Group Recommends Implementing Oncology Payment Model Based on ASCO’s PCOP. asco.org website. https://www.asco.org/advocacy-policy/asco-in-action/hhs-advisory-group-recommends-implementing-oncology-payment-model. Published December 19, 2018. Accessed November 21, 2019.
