From angst to analytics: lessons learned from an oncology care model internal pilot

In March 2016, 13 practices affiliated with the US Oncology Network (USON) were invited to participate in the Oncology Care Model (OCM) proposed by the Center for Medicare and Medicaid Services (CMS) and Center for Medicare and Medicaid Innovation (CMMI). The OCM, a novel value-based care model, was designed to provide higher-quality and better-coordinated oncology care at a lower cost to CMS.¹ Of the 13 practices, 12 agreed to participate with a start date for the program of July 1, 2016. At least 40% of the practices’ patients were insured by Medicare, and any eligible patients with active cancer were offered an opportunity to enter the program. USON practices treat more than 25,000 patients with a qualifying episode per year and the overall OCM program sees more than 150,000 beneficiaries per year,² so we anticipated that the OCM would have a substantial impact on each of the 12 practices on USON.

Faced with the scenario of having only 3 months between notification of approval and launch of the OCM, it was imperative that all the practices be proactive in planning and preparing to launch the OCM. With this goal in mind, representatives from all OCM candidate practices convened to anticipate the needs of the OCM and chart out a program to meet those needs. In this article, we discuss the requirements and scope of the OCM, the development of an internal pilot project, the anticipated gains from the pilot, and the results and findings from the pilot, both expected and unexpected.
 

The road to the Oncology Care Model

The government and oncology practices have been on separate trajectories to the OCM. In the last 15 years, the major intersections of these trajectories had to do with price and not patient outcomes. In 2003, the Medicare Prescription Drug Improvement and Modernization Act (MMA) focused on drug price reductions from an average wholesale price–based schedule to an average sales price–based schedule.³ There was the sequester in 2013,⁴ and more recently a proposal to restructure the payment for Part B drugs. In the background, recurrent negotiations to fix the calculation for the sustainable growth rate allowed for periodic draconian cuts to the prices of services. The cumulative effect of these price reductions has been to put economic pressure on community oncologists such that many have moved to a hospital environment.⁵

This contentious relationship with community oncology began to change with the passage of the Affordable Care Act (ACA) in 2010.⁶ Section 3022 of the ACA established the Medicare Shared Savings Program (MSSP) with the charge to create a new type of health care entity that was responsible for achieving the triple aim of improving population health, improving individual patient care, and bending the cost curve.⁷ Additional programs, such as the Pioneer Accountable Care Organization (ACO) program and the Comprehensive Primary Care Initiative were established to test alternative payment models.^8-10

The ACA also funded the CMMI with a mandate to “test innovative payment and service delivery models” to achieve the triple aim; US$10 billion were appropriated for the years 2011-2019 for this purpose. The CMMI funded a pilot project for cancer care, the COME HOME [Community Oncology MEdical HOME] initiative, to test whether some aspects of care could be transformed or augmented to reduce overall costs or at least reduce the rate of increase. Findings from COME HOME have helped inform the OCM program.¹¹

Over the same period, practices belonging to the USON were paving a path toward value. An electronic health record (EHR) for the entire network was adopted in 2005. A pathways program in which chemotherapy regimens were assessed on cost as well as benefits and toxicity, was started in 2006. Higher-cost regimens with no additional benefits comparable with other evidence-based regimens were deselected for initial treatment choices at the time of initial decision support. This process was streamlined using web-based technology that improved pathways compliance and tracking of off-pathways exceptions.¹² Retrospective studies indicated that pathways had the potential to bend the cost curve by reducing drug spending.^13,14 USON and its practices also tested a nurse call system (Innovent Oncology) funded by a monthly management fee. This program guided patients through chemotherapy with regular telephonic symptom assessment and discussion of patient-centered values and advance care planning. Results of these programs indicated relative reductions in both drug and hospital expenses.¹⁵

Additional experience has come from participation in the United Healthcare Episodes of Care (EOC) initiative, which eliminated the chemotherapy drug incentives, compensating physicians on a per-episode basis instead. This study showed a significant reduction in the total cost of cancer therapy after modifying the fee-for-service system and incorporating feedback data and financial incentives to reward improved outcomes and cost efficiency.¹⁶

The Oncology Care Model represents a convergence of purchaser demand and provider readiness. The purchaser holds providers accountable for cost and quality. The data on outcomes and costs will provide an extensive database that can be analyzed by the participating practices to address variations and reduce unnecessary care and preventable costs. Best practices are rewarded.¹⁷