Enhancing Value-Based Oncology Care: What Has CMMI Learned From the OCM?
We previously wrote about lessons from the Oncology Care Model (OCM) that the Center for Medicare and Medicaid Innovation (CMMI) could apply to the Enhancing Oncology Model (EOM). Subsequently, CMMI recently released an evaluation report for the first nine of the 11 total 6-month performance periods of the Oncology Care Model (OCM).
What CMMI Learned About OCM
CMMI’s latest report revisits much of what we already knew about the OCM:
- Episode payments for OCM practices rose less rapidly (on average by $499 less) than comparison non-OCM episodes. Reductions were largest in episodes for patients with high-risk cancers. Episodes for low-risk cancers did not show payment reductions. Reductions were due in part to lower spending on non-chemotherapy drugs to prevent neutropenia, nausea, and cancer-related bone fractures.
- Despite the reductions in gross Medicare spending, Medicare ultimately lost $528 million on OCM after Monthly Enhanced Oncology Services (MEOS) and performance-based payments were made to practices.
- OCM demonstrated some improvements in the quality of care for cancer patients, including reductions in the probability for intensive care unit admissions, a small decrease in the likelihood of an emergency department visit leading to an inpatient stay, and a reduction in the number of readmissions and unplanned readmissions among patients with at least one readmission. Other measures of quality (for example, patient experience rating) remained constant.
- The report reiterated that, aside from the adoption of lower cost biosimilar cancer treatments, participation in the OCM did not show cost-biased selection of chemotherapy treatments or impaired access to high-cost therapy.
The recent OCM evaluation report revealed new information about the effect of policy changes in response to the COVID-19 public health emergency (PHE). Those policy changes drove higher payments to practices that offset Medicare’s savings and contributed to the OCM’s net losses. During the PHE, practices that were confident in their ability to achieve performance-based payments (PBPs) were able to adopt two-sided risk and benefit from PHE policy changes to the quality measure benchmarks that made it easier for them to achieve PBPs. Practices that were not as confident in their ability to achieve PBPs were allowed to opt out of financial reconciliation and not be subject to downside risk, while continuing to receive MEOS payments.
The latest evaluation report also shares insights into the impact of OCM on health inequity for Black, Hispanic, or dually eligible Medicare/Medicaid patients. Baseline data showed that these populations were more likely to utilize hospital-based care, were less likely to have timely initiation of chemotherapy after surgery, had lower adherence to oral medications, and were less likely to receive hospice care at end of life. While inclusion in OCM improved medication adherence among these historically underserved populations, there were no improvements in other quality measures analyzed for disparities.
Implications for EOM
These findings reinforce the rationale for many of the changes that CMMI made for the EOM, the successor to the OCM that began July 1, 2023:
- To counter the risk for net losses to Medicare, CMMI made three notable changes for the EOM: First, they removed low-risk cancer episodes from the model and are instead focusing on seven types of cancer (breast, chronic leukemia, small intestine/colorectal, lung, lymphoma, multiple myeloma, and prostate cancers). Second, EOM only includes two-sided risk arrangements. Third, CMMI substantially lowered the MEOS payment amounts it will make to practices, from $160 under OCM to $70 under EOM, with an additional $30 for dually eligible beneficiaries because they are more complex to manage.
- To advance the Biden-Harris Administration’s goals to address health care disparities, CMMI added requirements for EOM practices to identify beneficiary health-related social needs using a screening tool that focuses on areas such as transportation, food insecurity, and housing instability. EOM practices are also required to develop a health equity plan that identifies where disparities may exist in their population and evidence-based strategies they will use to address the disparities.
Other aspects of the EOM remain largely the same as the OCM. CMMI has not made substantial changes to the quality measure set for EOM, which continues to focus on utilization (including at end-of-life), pain assessment and management, depression screening, and patient-reported experience of care. Like the OCM, the EOM also eschews quality measures that assess appropriate use of treatment or follow-up, which could counterbalance cost-containment incentives under the model. Quality measures assessing appropriate treatment initiation in cancer care are challenging because of rapidly evolving therapies, but CMMI should consider adding measures where high variation in evidence-based care exists, such as timely biomarker testing to guide personalized medicine. CMMI should also consider measures for EOM that focus on supportive care for novel immunotherapies, such as the Society for Immunotherapy of Cancer’s immune-mediated adverse events measure, recently implemented in the Merit-based Incentive Payment System (MIPS).
Filling gaps in cancer quality measures is an ongoing challenge. Performance measures are absent for critical outcomes, such as mortality and survival. Like OCM, the EOM does not include patient-reported outcome performance measures (PRO-PMs) that evaluate changes in symptoms or treatment side effects over time. However, the EOM differs from OCM in its requirement for practices to collect electronic patient-reported outcome (ePRO) data on symptoms and/or toxicity, functioning, health-related social needs, and behavioral health. This may suggest a stepwise approach to establishing infrastructure for EOM practices to eventually report PRO-PMs built on ePRO data. New measures, funded through the legislation that created MIPS for clinicians and focused on evaluating changes in pain and fatigue, have recently been endorsed and may be options for the EOM.
It is challenging to predict whether the EOM will achieve its goals with more success than the OCM. While CMMI has addressed some of the policy issues that led to net losses under the OCM, these changes appear to have had a chilling effect on participation in the EOM, with 44 sites of care participating compared with 122 practices at the end of OCM (of note, EOM sites of care may contain multiple practices, affecting the comparison). It will continue to be important for CMMI and model evaluators to analyze the effects of two-sided risk on quality of care and longer-term outcomes for patients, and to understand how the model is helping address health care disparities for Medicare’s most vulnerable beneficiaries.
About the Quality Outlook Commentary Series
Breakthrough treatments in cancer care, including precision therapies tailored to specific patient factors, are driving rapid changes in the definitions of oncology quality and value. Efforts to implement value-based care models in oncology must meet the demands of evolving science, new best care practices, and shifting patient priorities. Quality measures must be up-to-date and relevant. Payment models must recognize the challenges and costs of managing complex patient populations with diverse needs. In this JCP blog series, Quality Outlook, Real Chemistry will explore key issues in oncology quality and value through posts focused on measurement, value-based payment, and quality improvement.
About Tom Valuck, MD, JD
Tom Valuck, MD, JD, is a Partner at Real Chemistry. He is a thought leader on health care system transformation and helps lead the firm’s focus on achieving better health and health care outcomes at a lower cost. Tom’s work at Discern includes facilitating the exploration of next-generation measurement and accountability models for health care delivery systems. He also helps clients develop strategies to achieve success within the value-based marketplace.
About David Blaisdell
David Blaisdell, a Director at Real Chemistry, leads and manages client projects, providing insight and subject matter expertise, particularly on quality landscape analyses and measure gap identification. David has led and contributed to projects focused on oncology quality measurement to identify key gaps in measures used in accountability programs and opportunities for measure development. Through this experience, David helps clients navigate measurement and value-based payments and define strategies for success.
About Real Chemistry
The Real Chemistry Market Access team uses research and strategic advisory services to help our clients improve health and health care through value-based payment and delivery models. These models align performance with incentives by rewarding doctors, hospitals, suppliers, and patients for working together to improve quality while lowering total costs. Real Chemistry is an independent provider of analytics-driven, digital-first research, marketing services, and communications to the healthcare sector.
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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Journal of Clinical Pathways or HMP Global, their employees, and affiliates.
