As the Center for Medicare and Medicaid Innovation (CMMI) continues to learn, shape, and test alternative payment models, key decisions must be made around which components of inaugural models to continue or retire. The CMMI released the Oncology Care First (OCF) Request for Information (RFI) in November 2019 and suggested removing hormonal-only therapy episodes from the model reconciliation process. If included in the forthcoming OCF Request for Application (RFA), practice performance would be evaluated solely on episodes for beneficiaries undergoing active treatment. The impact on performance and potential unintended consequences of such decisions are important to consider in future model design.

The OCM is an episode-based, oncology-focused payment model led by the CMMI that aims to improve care coordination and reduce costs for Medicare fee-for-service (FFS) beneficiaries. The model evaluates the total cost of care for 6-month episodes initiated by chemotherapy treatments attributed to oncology practices voluntarily participating in the model. For each of the 11 OCM performance periods (PPs), the CMMI measures practice performance based on total expenditures relative to a benchmark price. Dependent on a practice’s performance and elected risk track (1-sided risk, original 2-sided risk, or alternative 2-sided risk) in a given performance period, practices may earn performance-based payment (PBP), fall in the safe zone, or owe a recoupment to the Centers for Medicare & Medicaid Services (CMS).

Initially, the CMMI evaluated practice performance based on 21 cancer types, including breast, prostate, and bladder cancers. Beginning in PP3, the CMMI refined the methodology and designated breast and bladder cancers as high and low risk and prostate cancer as high and low intensity. These risk/intensity groups are defined by the type of treatment received during the episode. While all high- and low- risk episodes are included in the OCM reconciliation process, the OCF RFI proposed that low-risk/low-intensity episodes be excluded from  OCF reconciliation methodology. About 33% of all OCM episodes are considered low risk/low intensity but account for only 8% of total OCM expenditures.

To understand the impact this change may have on overall practice performance, Avalere replicated the OCM methodology, excluding the low-risk/low-intensity episodes and compared this simulated performance to performance based on the current OCM methodology.

Results

Avalere assessed the practice-level impact of removing low-risk/low-intensity episodes on performance under 1-sided risk and alternative 2-sided risk for PP3 through PP6. Although practices could not enroll in alternative 2-sided risk until PP6, both risk tracks were evaluated over this period because historic performance in down-side risk may influence practices’ future decision-making.

Practices enrolled in 1-sided risk may earn a PBP but are not at risk for owing a recoupment to the CMS. Assuming all practices were enrolled in 1-sided risk in PP3 through PP6, Avalere analysis estimated the following changes if low-risk/low-intensity episodes were removed from reconciliation (Figure 1):

• The majority of practices (93–97%) remained in the same performance zone (i.e., PBP or no PBP) in PP3 through PP6
• Among practices whose performance changed in PP3 through PP6, performance would improve for most (62–80%)

Note: This analysis includes 174 OCM practices in PP 3–4 and 172 OCM practices in PP 5–6. Improved performance indicates the practice did not earn a PBP when low-risk/low-intensity episodes were included but would have earned a PBP if removed.

Practices enrolled in alternative 2-sided risk may earn a PBP, fall in the safe-zone, or owe a recoupment to the CMS. The alternative 2-sided risk track differs from original 2-sided risk track because it includes the safe-zone, which indicates savings below the benchmark price but not enough savings to earn a PBP. If a practice is in the safe-zone, they do not earn a PBP or owe a recoupment. Avalere analyzed how practice performance may change after removing low-risk/low-intensity episodes, assuming all practices were enrolled in alternative 2-sided risk.

• Most practices (91–96%) remained in the same performance category (i.e., PBP, safe zone, or recoupment) in PP3–PP6
• Among practices whose performance changed in PP3, PP5, and PP6, most practices’ performance would have worsened (6 of 10, 11 of 15, 10 of 15 practices, respectively)
• In PP4, 7 of 15 practices with a performance change would have improved

Figure 2 summarizes the number of practices whose performance changed based on movement across performance categories for each PP. Avalere did not find an association between the change in performance and proportion of low-risk/low-intensity episodes at each practice.

Note: This analysis includes 174 OCM practices in PP3–PP4 and 172 OCM practices in PP5–PP6. The number in each circle represents the number of practices that experienced a given change in performance. Improved performance includes safe zone to PBP, recoupment to PBP, and Recoupment to safe zone. Worsening performance includes safe zone to recoupment, PBP to recoupment, and PBP to safe zone

What’s Next?

As providers continue to pursue episodic-based care in oncology, and as the OCM evolves into the OCF model, it is important to understand how methodological changes may impact practice performance, especially for cancer programs intending to transition from participation in OCM to the OCF Model.

In addition to understanding how methodological changes may impact practice performance, stakeholders should also consider unintended consequences of such changes. The CMS is seeking to balance how it approaches low-risk/low-intensity episodes with those undergoing active treatment in a way not only incentivizes management and surveillance but also maximizes performance opportunity. To do so, the CMMI suggested expanding the OCF model to include attributed beneficiaries who would be eligible for a Monthly Prospective Payment (MPP) but are not included in reconciliation.

Methodological changes suggested in the OCF RFI—such as those described above, as well as a tumor-specific trend factor and novel therapy adjustment and the transition from the Monthly Enhanced Oncology Services payment to the proposed MPP—are important components for practices to consider relative to overall practice economics. Stakeholders are eagerly awaiting the release of the OCF RFA to understand how the CMMI will manage and account for beneficiaries with cancer when surveillance or long-term hormonal therapy, instead of active treatment, is the course of treatment.

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Methodology

Avalere performed this analysis using Medicare Part A/B FFS claims and Part D prescription drug event data under a CMS research data use agreement. Avalere replicated the OCM payment methodology developed by the CMS, including the attribution of episodes to practices, the assignment of cancer type, and the calculation of benchmark prices. Participants were identified in the claims data through tax identification numbers (TIN) reported on Part B claims. Avalere identified 174 practices that were ever enrolled in the OCM through TIN mapping and general research of oncology practices. The baseline period includes episodes initiated between January 1, 2012, and December 31, 2014, and the intervention period includes episodes initiated between July 2, 2017, and July 1, 2019 (PP3–PP6).

Avalere used the CMS’s definition of low- and high-risk breast and bladder cancer and low- and high-intensity prostate cancer. Because the methodology did not include risk stratification until PP3, the analysis does not consider PP1 or PP2. For the purposes of this analysis, Avalere assumed all practices were in the 1-sided or alternative 2-sided risk track for all periods. The 1-sided and alternative 2-sided risk results summarized above include 174 practices in PP3–PP4 and 172 practices in PP5–PP6 analysis due to a sample size limitation of 2 practices in later performance periods.