Medicare P4P Quality Supply of Medical Services

The Oncology Care Model is dead. Long Live the Oncology Care First Model.

The Oncology Care Model is slated to end soon. Specifically, the last set of six-month episodes would initiate no later than December 31, 2020 and thus all episodes will be completed in June 30, 2021. Nevertheless, CMS is proposing a successor to the Oncology Care Model called the Oncology Care First (OCF) Model. CMS describes the revised approach as follows:

…the payment mechanisms for the potential OCF Model would include: (1) A prospective, monthly population payment (MPP) for an OCF participant’s assigned population of Medicare FFS beneficiaries with cancer or a cancer-related diagnosis that would include payment for Evaluation and Management (E&M) services, “Enhanced Services” required under the terms of the model participation agreement, and drug administration services; and, (2) Total cost of care accountability for Medicare costs, including drug costs, incurred during a six-month episode of care triggered by a Medicare beneficiary’s receipt of a Part B or D chemotherapy drug, 6 with the opportunity to achieve a performance-based payment (PBP) or owe a repayment to CMS (PBP recoupment), depending on quality performance and costs relative to benchmark and target amounts

What are the differences between OCM and OCF? AJMC reports some key differences:

* CMS wants to shift some of the FFS payment to capitation, which “will pose challenges for OCF participants.” Evaluation and management (E/M) services and drug administration fees, which were previously outside the monthly practice transformation fee, would be folded inside it.
* Improved performance-based-payment formulas would do a better job of accommodating rapidly rising drug costs and protect oncologists from being held responsible for events that are beyond their control.
* New requirements may be added to require practices to gather patient-reported outcomes (PROs).

A Health Affairs commentary by de Brantes and co-authors is skeptical that OCF will be a significant improvement over OCM.

…today’s OCM are completely unpredictable because the actual expenses may vary from baseline depending on the specific nature of each cancer treated. Moreover, in OCF as in OCM, the treating physician is at risk for total costs of care, including services having nothing to do with cancer, like care after a car accident or for brittle diabetes. Adequately risk adjusting for each cancer type and stage across all possible cancers, including underlying patient-specific characteristics, seems all but impossible.

Research by my colleagues Jim Baumgardner and colleagues (Baumgardner et al. 2018) quantifies some of the variation in cost types across OCM episodes.

Implementation of OCF, however, has been pushed back due to COVID-19. The presence of a pandemic makes implementing payment reform problematic. As Lucio Gordan, MD–president and managing physician at Florida Cancer Specialists–mentions at AJMC:

But during COVID-19, it’s really a bad time to do new models and experimenting or pushing the envelope too quick, too hard, because we are under a tremendous amount of stress, and none of us wants to fail and not deliver and have consequences in terms of 2-sided risk for our practices that could impact access to care to our patients.
For Oncology Care First, I’m happy that they pushed back 12 months for 2022. We may need more time, but we’ll see how this plays out.

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