Value Transformation: Observations on the Second Annual Evaluation Report of the Oncology Care Model

The Centers for Medicare & Medicaid Services (CMS) posted its second annual evaluation report of the Oncology Care Model (OCM) in December 2018, covering first performance period and model year results. This article offers observations, based on data from the second annual report, on potential opportunities for improvement in utilization and other quality measures through continued emphases on end-of-life (EOL) care, chemotherapy side effect management, access facilitation, behavioral health/oncology care integration, and uniform adoption of quality improvement models. OCM quality measurement and improvement efforts continue to mature, and insights gained from early performance have potential applicability to the transformation of oncology and other specialty practices, as well as primary care.

Legislation under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established a novel approach to value-based reimbursement with the Quality Payment Program (QPP). Under the QPP, two pathways to payment were established: the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (Advanced APMs).¹ The 2-sided OCM is an example of an Advanced APM, and the 5-year model (2016-2021) was designed to promote high-quality and high-value cancer care through a value-based reimbursement strategy incentivizing the transformation of cancer care delivery.^2,3

In December 2018, CMS published The Report of the Oncology Care Model (OCM Report) summarizing results for Performance Period One and describing the efforts of OCMs to transform their practices for better value and population health.⁴ The OCM Report included data about 6-month episodes that began and ended during the first performance period (ie, began July 1, 2016-January 1, 2017, and ended by December 31, 2016-June 30, 2017). In many instances, data was compared with data collected from a group of non-OCM oncology practices that had been selected during the baseline period and found by the evaluators to be similar to the OCM practices along many dimensions.⁴

The OCM measures practices’ performance on an array of quality measures, including emergency department (ED) utilization and hospital admissions.⁵ The report did not address quality measure changes initiated after that period. For example, although ED and hospice utilization continue as performance measures, a related measure (hospital admission rates) is retiring beginning the fifth performance period, and measures assessing pain and depression care transition to pay for performance in the sixth performance period.⁵

Prevention of avoidable ED visits and hospitalizations is one of the primary emphases of the OCM. This article summarizes data from the OCM Report pertinent to utilization of emergency and inpatient services and offers some observations on factors potentially contributory to areas of favorable performance, as well as factors suggestive of potential opportunities for improvement, particularly as they impact ED and hospital use. These factors may be of interest to both OCM and non-OCM oncology practices seeking to transform their delivery of care to improve population health and offer better value for patients and payers. Non-OCM practices may be participating with other value-based reimbursement models, such as the MIPS arm of the QPP, in which their Medicare reimbursement is impacted by performance in 4 areas, including quality and cost.⁶

Advance Care Planning

The OCM Report noted a greater decline in all hospital utilization measures among the OCM practices, compared with non-OCM comparison groups, during this early OCM phase. Two of the declines, although noted as small, were nevertheless statistically significant: inpatient hospitalizations that included intensive care unit (ICU) stays and ED visits.⁴ The evaluators plan further analyses to determine the drivers of decreased ED use, but observed that  “the OCM emphasis on advance care planning may be contributing to the estimated reductions in inpatient and ICU admissions for dying OCM patients, relative to the comparison group.”⁴ Analysis of surveys of bereaved family members of patients who died in OCM found that avoidance of hospital-based care at the EOL, earlier transition to hospice, and dying at home were more aligned with patient preferences and associated with better family-member ratings of overall care at EOL.⁷

Opportunities for improvement remain; the authors noted that, although OCM practices may be discussing hospice care with dying patients more, greater use of hospice care or improved timing of hospice entry is not yet evident.⁴ Continued focus by OCMs on advance care planning, including use of palliative care and discussion of hospice services,⁸ could further support appropriate utilization of ED and inpatient care, greater levels of patient and family satisfaction, and improved performance on the OCM quality measure assessing timely hospice utilization.⁵

Chemotherapy Side Effect Management

Concurrent medication education on oral and infusion chemotherapies and symptom management services have the potential to optimize patient care delivery via early interventions for adverse drug events, drug interactions, and medication errors.⁹ For example, Wong et al¹⁰ showed that an oral chemotherapy management pharmacy clinic offering patients chemotherapy management, concurrent medication education, and symptom management services could decrease the incidence of adverse drug reactions, drug interactions, and medication errors with favorable cost avoidance estimates.

Although OCM practices are working to identify and support patients at risk for chemotherapy toxicities, the OCM Report noted, there had not yet been a measurable impact on ED visits or hospitalizations for complications from chemotherapy.⁴ The OCM Report documented guideline-recommended use of antiemetics—including use of higher vs lower-intensity guideline-recommended antiemetic regimens—and noted that “antiemetic therapy for patients undergoing emetogenic infused chemotherapy did not change in the OCM group relative to comparisons” during the measurement period.⁴ Of note, clinical decision support (CDS) tools to facilitate guideline adherence were reported as being integrated with the electronic health record (EHR) by only 66.7% of the practices, with even fewer (55.7%) of the practices reporting CDS integration within their chemotherapy electronic order management systems in 2017.⁷

With regard to oral chemotherapies, the OCM Report stated that the proportion of episodes triggered by a Part D chemotherapy drug (ie, prescribed oral therapy) increased between baseline and intervention periods.⁴ However, variability existed among practices with regard to side effect communication and assistance and proactive monitoring for adverse effects and adherence.⁴ The evaluators intend to further monitor utilization of Part B and Part D chemotherapies and patient support for managing side effects.⁴

Additional interventions to prevent chemotherapy-associated ED and hospital admissions, and interventions to promote appropriate medication adherence and to prevent wastage, may yield improvements not only with hospital utilization but also with chemotherapy utilization. Implementation of the practice transformations listed in Box 1 may yield better value for OCMs in future reports.

Facilitation of Access to Care

One of the aims of the OCM is to offer better coordination of care and access to the patient’s oncology care team through greater use of enhanced services, resulting in reduction of unnecessary utilization and lower costs.⁴ The OCM Report evaluators developed composite patient satisfaction survey scores measuring satisfaction with access before and after the OCM’s inception; these scores showed high satisfaction levels for both periods.⁷

However, a review of Practice Transformation Plans (PTPs) annually submitted by OCM practices (N=183) suggests opportunities for further facilitation of care access, with the potential for reducing unnecessary ED and inpatient utilization. Analyses indicate strong performance on some access-facilitating services such as offering same day appointments (95.1%), but others such as providing access to extended evening hours (37.7%) and weekend hours (36.1%) were far less frequent among the OCM practices.⁷ As OCM participants evolve, more practices with sufficient patient volume should opt to develop oncology-dedicated urgent care clinics with extended hours, such as those launched by Johns Hopkins, The University of Texas Southwestern Medical Center, and Oncology Hematology Care with favorable clinical and financial results.^11,12

OCM participants are continuing to evolve their core patient navigation functions. One function that could support appropriate ED and hospital utilization is arrangement of transportation. Transportation is a commonly cited social determinant of health care presenting access challenges for both urban and rural patients and providers, and the American Hospital Association (AHA) has noted that its impact can be felt in multiple ways, including the cost of missed appointments, delayed care, and increased ED visits, as well as decreased pharmacy access and prescription fills.¹³ The OCM Report indicated that some OCM practices noted a lack of transportation access in rural areas, and only 54.6% of the 183 practices in the PTP analysis reported arranging transportation for their patients.⁴

More OCM practices should consider extending telephone visits and 2-way video visits, particularly for patients with limited transportation access. Only 30.6% of the practices included use of telephone visits and even fewer (10.9%) offered video visits in their 2017 PTPs.⁷ A joint survey of the Association of Community Cancer Centers and the Oncology Roundtable (N=205) indicated that oral chemotherapy adherence education and support, symptom management consults, and follow-up visits were among its most popular services currently provided via telehealth, and 67% cited partnerships with organizations to provide patient transportation as a popular strategy for addressing access-to-care concerns.¹⁴

These data suggest that collaborations to expand access via telehealth and transportation options will increasingly be adopted by both OCM and non-OCM oncology practices. Practices should consider developing a concierge-like approach to better address social determinants of health—including transportation, child or elder care, and food insecurity—either directly or through vendors. Future OCM reports may shed light on their adoption by OCMs and potential impacts on ED, hospital, and medication utilization as well as patient satisfaction. 

Management of Pain and Depression

Among patients undergoing active cancer treatment, pain is one of the most common causes for ED visits and subsequent hospitalizations.¹⁵ Many ED visits for pain are preventable, and they can generate additional costs, diminished patient and family satisfaction, and subject immunocompromised patients to greater risk of infection.¹⁵ Depression is a comorbidity for 15% to 25% of cancer patients;¹⁶ yet, most may not be receiving depression care.¹⁷ Further, there is a higher rate of first hospitalization for depression among cancer patients (compared with the cancer-free population) with the highest rates occurring during the first year after diagnosis.¹⁸ Of particular note, is that the cancer-associated suicide rate is nearly twice that of the US general population, with the risk greatest among lung cancer patients.¹⁹ Therefore, it is not surprising that quality measures addressing quantification and treatment of pain, and screening and treatment of depression, are included in the OCM quality measure set.⁵

In the OCM Report, evaluators created a composite measure (Enabling Patient Self-Management) based on questions inquiring whether patients talk with their care team about pain, changes in energy levels, and emotional problems such as anxiety or depression. This composite score influences practices’ performance-based payments. The Report authors found similar composite scores (6 of a possible 10) among intervention and comparison survey respondents in the baseline survey. The evaluators concluded that “in both groups, practices have room to improve.”⁴ Further, when surveyed about whether their care team helped them deal with pain, adjusted mean patient survey responses ranged between 74.1% and 75.8% during the intervention period, with no statistically significant difference from baseline.⁴

Results were less positive for responses pertinent to anxiety and depression symptoms. When patients were surveyed about whether their care team helped them deal with emotional problems, adjusted mean survey responses ranged between 45.5% and 48.9% during the intervention period, although evaluators noted a positive trend over time (P < .10).⁴

These results suggest that opportunities exist for OCMs to better address patient pain and depression through systematic screenings with validated tools and more comprehensive integration with behavioral health care, which may potentially avoid unnecessary ED and hospital use. Behavioral health clinicians with expertise treating oncology patients and their families, including depression, anxiety, pain management, and suicide prevention, should be integrated within practices. Development of written agreements with oncological behavioral health partners—including robust protocols for routine, urgent, and emergent referrals and appointments, with bi-directional clinical data exchange—can facilitate smooth care transitions.

Use of a Formal Quality Improvement Model

To succeed in a value-based ecosystem, it is imperative that OCMs commit resources to the practice of continuous quality improvement (CQI), with consistent application of a framework such as the Model for Improvement²⁰ or the Framework for Cancer Quality Improvement.²¹ Despite the availability of quality improvement models, analyses of the 2017 PTPs in the OCM Report found that only 62.3% of the OCM practices (N=183) indicated they were employing a formal model of quality improvement. Practices owned by hospitals or health systems were more likely (83%) to formally use a model, whereas only 42.3% of the independent practices reported formal model use.⁷ Evaluators also observed variability among practices in the use of clinical pathways to support adherence with evidence-based guidelines commonly used to reduce treatment variations.⁴

Opportunities exist for stakeholders collaborating with OCM practices (eg, health systems and plans, specialty pharmacies, pharmacy benefit managers, Part D plans, and pharmaceutical manufacturers) to support OCMs’ quality improvement initiatives with training, tools, analytics, and consultation to promote population health. Practices seeking additional structure are referred to the National Committee for Quality Assurance (NCQA) Oncology Medical Home Recognition Standards and Guidelines,²² NCQA Population Health Management Resource Guide,²³ and the American Society of Clinical Oncology’s Quality Training Program.²⁴

Conclusion

Value transformation is a multidimensional process, often occurring in incremental stages. As the OCM Report noted, meaningful transformation takes time, and there are early indications of progress during the first model year. Transformation can be accelerated through vigorous adoption of quality improvement models to systematically implement effective practices such as timely hospice transitions, proactive chemotherapy management, a concierge-like approach to tackle social determinants of health, and robust behavioral health integration with oncology care.

OCMs, patients, and families sustain each other through multiple networks within actual and virtual communities. Value transformation can gain further momentum through strategically leveraging other health care stakeholders’ resources for better population health. Finally, although most progress is incremental, occasionally exponential progress can occur through consideration of delivery models outside the domain of health care.

References

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11. Cohn M. Hopkins expands urgent care to cancer patients. The Baltimore Sun. November 25, 2016. https://www.baltimoresun.com/health/bs-hs-cancer-urgent-care-20161122-story.html. Accessed February 20, 2019.

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23. National Committee for Quality Assurance. Population health management: resource guide. https://www.ncqa.org/wp-content/uploads/2018/08/20180827_PHM_PHM_Resource_Guide.pdf. Accessed February 20, 2019.

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