The Challenges With OCM
In beginning to understand the potential of OCF, it is important to review the challenges the oncology world feels with OCM. At a high level, OCM, which began in July of 2016, is a CMS payment model targeting oncology practices in an effort to better serve Medicare beneficiaries. The model was scheduled to end in June of 2021; however, with the recent global pandemic, CMS has extended OCM until June of 2022.2
By participating in the model, oncology practices strive to improve quality of care for their patients, as well as provide enhanced oncology services (also outlined by CMS). Payments within OCM provide practices with a monthly payment designed to cover the expenses of the mandated oncology care practice patterns, as well as a performance-based payment aimed to incentivize improving quality while reducing costs across cancer episodes.3
While the foundations of the model align with the overall oncology community’s commitment to value based care, there are a few pieces of the model that received feedback across the past years.
There are initial costs and burdens in building practice group infrastructure for OCM.
Across participants, many practice groups have mentioned the costs they incurred to train up their staff on the new model and develop the internal infrastructure to coordinate care. Like many new things that require investment, this is not unheard of. Yet, in reviewing the model, practices also frequently note extensive reporting criteria for model participants, particularly around the labor of aggregating quality metrics from multiple sources and places.4
OCM’s payment structure does not reflect the current state of novel treatment prices.
Since OCM was introduced in 2016, it’s payment structure is founded on claims data before 2015. With the vast changes to oncology treatments between 2015 and 2020, many practices feel the pricing structure of the model does not accurately take into account the pricing treatment offerings that have been introduced more recently. As a result, some practices feel there is a penalty for using more current treatments that are sometimes more expensive.5
Many practices struggle with the attribution of patients.
For many of the CMS payment models, the number of attributed patients is a key factor. In OCM, oncology practices have expressed a variety of challenges around attribution. For example, to identify the number of attributed patients, practices can look to see which patients have received chemotherapy. However, this is much more complicated for patients who are receiving oral chemotherapy. Additionally, many practices hope for reform to the monthly payment attribution process.6
With this feedback in mind, CMS introduced the new model, OCF, colloquially referred to as OCM 2.0.
An Overview of OCF
Oncology Care First (OCF), similar to the CMS’ OCM, is another model intending to promote coordinated, holistic oncology care for patients while reducing overall costs. The model is available to physician group practices or hospital outpatient departments.
Similar to OCM, to participate in the model, practices must7:
- “Offer beneficiaries 24/7 access to a clinician with real-time access to their medical records;
- Provide the core functions of patient navigation;
- Document a care plan for beneficiaries that contains the 13 components of the Institute of Medicine’s (IOM) Care Management Plan;
- Treat beneficiaries with therapies consistent with nationally recognized clinical guidelines;
- Use Certified Electronic Health Record Technology (CEHRT) as specified in regulation;
- Utilize data for continuous quality improvement; and
- Gradually implement electronic patient-reported outcomes (ePROs).”
The OCF model combines both upside and downside risk for it’s oncology practice groups and offers 3 risk tracks: (i) upside risk, (ii) downside risk, (iii) blending of other two risk tracks. For any practices transitioning from the sunsetting OCM model to OCF, there is a requirement to take on downside risk to participate. Other practices dipping their toe into the water of value-based oncology are eligible for a one sided risk track for a defined period of time as they grow accustomed to the model.
In terms of the payments, OCF provides two types of payments for members.
- The first is the Monthly Population Payment (MPP). This is a fixed capitated payment that provides OCF practices a set sum for E&M services rendered by a medical oncologist. This sum is calculated based on the practice’s full Medicare population and includes patients who are treated with chemotherapy and those that are not.
- The second is the Performance Based Payment (PBP). This payment mirrors the performance payments in OCM. The payment holds OCM practices responsible for the total cost of care (including drugs) across a patient’s six-month episodes. With this payment, if practices see total costs of care below the benchmark (both from a cost and quality perspective), then they receive the PBP. On the other hand, if practices exceed the benchmark, then they owe CMS a PBP recoupment. For the PBP, an episode is triggered by chemotherapy and only applicable for beneficiaries enrolled in Part B or Part D Medicare fee-for-service.7
The Impacts of OCF
While there are many similarities between OCM and OCF, there are also a few key distinctions. An article in the National Law Review mentioned three of the main ones;
OCF expands the number of eligible beneficiaries for practices.
This is a significant change. Previously in OCM, beneficiaries were limited to patients who were receiving chemotherapy. This was also further complicated by the challenge around understanding when patients received oral chemotherapy (as mentioned above). While the calculation is still a bit uncertain for the MPP, in OCF, it is understood that the beneficiary criteria for the MPP is much more extensive than OCM. In fact, the payment will be calculated based on patients who are treated with chemotherapy, hormonal therapy, or without cancer drugs – a significant departure from the former model.8
OCF simplifies OCM’s historical MEOS payment into one simple MPP.
In addition to the critiques above, many felt that OCM lacks transparency for the payment calculations and that the process is too complicated. The OCF model aims to simplify the calculations for the MPP into one prospective payment with no special retrospective FDA carve out, like in OCM. When taken into account across OCF’s expanded definition of attributable beneficiaries, this has the potential to significantly change things for practices.
OCF incorporates cancer type into the novel drug adjustment.
Another big change for the OCF model targets some of the feedback around the novel drug therapy prices. Specifically, OCF will now take into account cancer type when calculating the novel drug adjustments. This is impactful for practices, as drug prices can vary by cancer type.9 This sensitivity will allow for those practices that commonly deal with the high cost cancer medications to also participate in the model.
To further assess the impacts of the OCF model, CareJourney projected payments under the new criteria for 2019 as a point of reference. These are available by geography in the dashboard linked above for both the PBP and the MPP. However, a few interesting takeaways on the PBP are summarized below.
OCF PBP episode payments differ by state, but this does not appear to be related to the state’s total number of episodes.
Looking on the state level for 2019, Missouri and Kansas would have had the highest average PBP per episode cost with a total of $42,957 and $42,843, respectively. On the other extreme, Rhode Island and the Virgin Islands would have had the lowest per episode cost of $8,559 and $4,097, respectively.