With the OCM set to end by 2022, uncertainty around what comes next for oncology value-based care is prompting some debate about the model’s success to date and questions about its future. The CMMI’s latest OCM evaluation report noted net losses to Medicare of $315 million in the first 2 years of the model. Yet the trend shows that more practices earned a performance-based payment in performance period (PP) 4, signaling participants’ growing ability to reduce costs relative to their own historic benchmarks as they gained more experience and access to meaningful data.

For many OCM participants, the shift to 2-sided risk beginning in PP8 (January 2020) created a “moment of truth” period to evaluate how OCM is shaping payment reform and cancer care. As stakeholders wait for data from the public health emergency and return to focusing on risk-based arrangements, they must consider 5 things for the OCF model.

1. The COVID-19 Pandemic Will Continue to Impact How CMMI Approaches Oncology-Focused Alternative Payment Models

The COVID-19 pandemic has created significant delays and challenges in delivery of routine cancer care. Avalere research showed a significant drop in cancer screening, biopsies, surgery, office visits, and treatment for Medicare beneficiaries in the early months of the pandemic and few signs of full rebound to pre-COVID-19 levels.

Due to this disruption in the provision of cancer care and the volatility experienced by oncology practices, the CMMI announced a number of pandemic-related flexibilities, most notably waiving risk for current participants. Looking ahead to the OCF, to maximize OCF participation, the CMMI would have to balance the priority to shift greater risk to providers while accounting for the lingering effects of missed screening, treatment delays, and the differential impact of the pandemic across regions.

2. OCF Methodology Enhancements Will Better Account for Nuances in Cancer Care

Practice performance in OCM relies heavily on benchmark prices established by a prediction model that accounts for practices’ differential mix of oncology patients. One of the main concerns about the prediction model has been its ability to accurately estimate the cost of cancer care given the rapid evolution in cancer treatment paradigms.

The CMMI is likely to adjust the OCF benchmark prices by applying more tumor-specific methodology determining both the trend factor and novel therapy adjustment (NTA) at the tumor level. Analyses from Avalere on the NTA changes have shown that more practices are likely to benefit from such a change.

Yet even within the same tumor category, significant variation exists in treatment patterns and total cost of care. For example, a recent Avalere analysis showed substantial differences between earlier and later stage breast cancer episodes. Starting in the PP7 reconciliation process, the CMMI will apply a “metastatic adjuster” for breast, lung, and small intestine/colorectal cancer episodes to factor metastatic disease into the benchmark price calculation. Looking forward, it is important to monitor the CMMI’s use of other available clinical registry data to further inform model calculations, especially as delays in screening and care are expected to result in an increase in individuals presenting with advanced disease.

3. The Potential Expansion of the OCF Will Capture More Medicare Cancer Beneficiaries Under the Model

The proposed OCF methodology seeks to include beneficiaries beyond the scope of current attribution under the OCM in order to reform management of cancer care under the CMMI at a population level. In addition to patients actively receiving anti-cancer drug treatment, the OCF would also include beneficiaries under active surveillance or care management. Under the OCM, Avalere estimated that as many as 20% of Medicare fee-for-service beneficiaries with cancer were treated by an OCM practice. Changes to the patient attribution methodology could significantly increase the number of cancer patients affected by the model.

4. The OCF Model Payments Signal Movement Toward Capitated Payments

Under the OCF, the CMMI is considering a shift from the current monthly enhanced oncology services payment (MEOS), which is a flat per-episode-per-month fee, to a monthly population payment (MPP), a bundled prospective payment that also includes payment for services like evaluation and management visits and drug administration. The transition from MEOS to MPP signals the CMMI’s focus on continuity of cancer care after active treatment, but it may also offer the promise of greater savings, especially if additional services like labs and imaging are incorporated. While much remains unknown about how the MPP would be calculated, the pandemic-related treatment disruptions in oncology care may increase the attractiveness of predictable, prospective payments like MPP for providers.

5. The Final OCF Methodology May Include Changes Not Described in the Request for Information

As the CMMI shapes the OCF and prepares to announce more details in the coming months, it will need to find the right balance between a model that appeals to a broad array of oncology providers while also generating savings and serving the needs of diverse patients across the country. Considering broader healthcare trends, pressure from stakeholders, and the Medicare Payment Advisory Commission’s (MedPAC) recommendation to streamline the CMMI’s demo portfolio, additional areas might be considered as we wait for the final methodology release.

• Social Determinants of Health: Private payers have increased their focus on social determinants of health (SDOH). Many private payers have found ways to address SDOH by offering services related to housing and food insecurity. Moving forward, the CMMI may wish to address SDOH in the OCF by including data elements in the prediction model and requiring participants to connect patients with community resources as a mandatory care transformation activity. It could also pursue other changes that seek to close disparity gaps in cancer care, particularly in certain tumor types.
• Mandatory Model, Risk Arrangement in Select Tumor Types: The CMMI’s most recent evaluation report described significant reductions in total episode payment among high-risk breast, lung, lymphoma, and colorectal cancer episodes, signaling that certain tumors might be better targets for value-based incentives. This may lead the CMMI to consider a mandatory model or risk arrangement in select cancer bundles. Such a transition may be in line with MedPAC’s recommendation to streamline models and the commission’s preference to increase the use of mandatory models.

To learn more about Avalere’s work on oncology care, including the OCM and OCF, connect with us.