CMS: Oncology Care Model Will Be Tough But Worth It

Ron Kline, MD

As a medical officer at CMS with responsibility for putting together the Oncology Care Model (OCM), Ron Kline, MD, is accustomed to hearing oncologists’ concerns that the bar is being raised too high for them. Some contend that they are already practicing to the highest standards and are as efficient as they can be, Kline says. He responds with an anecdote about a time that he met with a group of such physicians.

“As we were walking out the door I said, ‘What I hate is when your patient ends up in the emergency department (ED) and you don’t hear about that, and 3 days later you find out your patient’s been admitted to the hospital.’ And to a person, every one of those practice physicians nodded and said, ‘Yes, that happens to me, too!’ I looked at them and said, ‘You know what? Fix that, and you have a lot of room for improvement.’”

The OCM launched this month after 2 years of preparation by CMS. There are 195 practices participating from across the United States. Practice administrators, physicians, and their industry representatives have expressed concerns about the complexity of the alternative payment model (APM), the sluggish pace at which CMS has completed the stages necessary for launch, and the clarity of the information CMS has provided.

In an interview with OncLive about the OCM, Kline, who works in the office in the Patient Care Models Group in the CMS Innovation Center, explained that there are bound to be technical difficulties with an ambitious program of this scope: “We have done our very best to really shape the OCM and to address concerns fairly. Obviously, you’re learning as you go and you’re fixing things as you go.” Practice representatives have steadily come forward with concerns that were not covered by previous guidance from CMS. “No matter how detailed you think you are, there’s somebody out there for whom it’s not detailed enough, and they’ve got a unique set of circumstances that they need to address,” Kline says.

Eventually, the OCM will deliver on its promise to achieve lower costs and better outcomes, Kline predicts. Nobody knows better than an oncologist what’s really going on with an oncology patient; therefore, the idea is to coordinate better with other specialists, so that patients get directed to the right care at the right time, he says.

For example, “If a physician gets a call at 6 am in the morning and the patient needs to be seen, one answer is, well, ‘Go to the emergency department.’ Another alternative may be for an oncologist to get out of bed a little earlier and meet the patient in the office at 7:30 am and try to deal with the problem in that way.”

CMS also wants to see practices adhering better to nationally accepted treatment guidelines. In some cases, not following guidelines is justified, Kline says, but “evidence has shown that when you follow national guidelines, you provide better care, patients do better, there’s less toxicity, and there’s actually more high-value care. Doing that is important.”

That makes it sound easy for physicians and CMS to achieve value-based goals under the OCM, but Kline acknowledges that the model has “many moving parts” and has been evolving over 2 years as CMS has tried to come up with a system that would work for all types of oncology practices across the United States.

Starting from the July 1 launch, there’s a 90-day grace period with relaxed standards, after which oncology practices will have greater responsibility for meeting goals. The refining and tweaking process will continue for the 5-year duration of the OCM, after which CMS expects to have a much more workable APM. Meanwhile, CMS will offer regular webinars and other types of support to help enrolled practices adjust to the tighter set of expectations.

CMS programs may be in flux as a result of congressional testimony this month by Acting Administrator Andy Slavitt, who said a delay in implementing the Medicare Access and CHIP Reauthorization Act (MACRA) is likely because many practices are not ready for the higher standards. However, Kline says the OCM technically will not be considered a part of MACRA until physicians enrolled in the OCM start to assume a two-sided risk framework with penalties for failure to meet standards.

Another possible change is a reduction in drug payments under Medicare Part B. Some OCM practices worry about having to shoulder this change in addition to the OCM requirements, but Kline says the proposed change remains under review, and he is not able to say whether OCM practices would be affected by it.

Among the shortcomings of the state of readiness of the OCM, the launch of a portal for data uploading has been delayed. Additionally, practices have said it hasn’t been possible for them to model their financial outcomes sufficiently to determine how much they will be able to earn under the model. Kline says progress has been made on both of those fronts, partly with the launch in recent weeks of OCM-PREDCT for modeling payment.

“You can plug in a diagnosis and a set of comorbidities, age and gender, and the model will predict what the target price will be. What’s not running is the software registry that would accept data manually from physicians or upload from their own electronic health records into ours. It’s a complicated piece of software that’s made more complicated by the fact that it has to be completely secure. It’s actively being worked on.”

One big concern from the Community Oncology Association (COA), which represents hundreds of independent practices and has been helping OCM enrollees to find answers to questions about the model, is that the OCM apparently forces practices to compete against their own achievements—meaning that if they achieve economies, they will be penalized financially if they don’t improve upon those same achievements in subsequent years.

Kline says that’s not completely true. Practices are expected to improve on their own performance, but “the goal posts don’t move. What we did was create a personalized benchmark for every practice, so that every practice can improve against its personal best,” but minimum performance levels won’t be raised to make it more difficult.

Some practices favor the establishment of regional standards that practices would have to meet. Kline says that wouldn’t have challenged the best oncology practices in a region to do any better, and it would have been unfair to other practices that have huge obstacles to overcome in delivering more economical care. “The much more challenged practices would be so far off the regional price that there wouldn’t be anything they could do. They wouldn’t even bother to participate in the regional model.”

It’s not just a matter of knowing how a practice is going to be judged under this model, or whether practices will have all of the information needed to make accurate predictions about how much they will earn in pay for a particular patient. Some practice representatives have said that they don’t know yet whether all of their financial investments in the OCM are going to be covered. For example, CMS has provided for $160 monthly payments to practices for each patient undergoing a 6-month episode of care.

Eventually, practices will share in the savings they achieve for CMS. However, from the start, practices have had to hire nurse navigators, assign workers to cover the extra hours required for 24/7 patient assistance, and foot the bill for additional software and related technological support in order to make the OCM system conversion. Some anticipate that the expenses won’t stop there.

For his part, Kline says that the $160 monthly payments were intended to cover those extra needs. In the end, he says, the OCM will lead to higher value care, though it’s not going to be easy for practices or for CMS to achieve.

“Yes, you have to do more things than before, but the OCM is compensating you for that. The things that you’re doing will improve the quality of oncology care for patients throughout the country. I don’t think anyone has said to me the things that we’re doing won’t improve the quality of care. They’ve said the things that we’re doing are hard, and I agree.”