Electronic PROs a Proposed Feature of Successor Model in Oncology Care

Electronic patient reported outcomes (ePROs) would be required under the successor to the Oncology Care Model (OCM), according to leaders from the Center for Medicare and Medicaid Innovation (CMMI) who led a listening session Monday with practices that currently take part in the OCM.

While oncologists didn’t object to the concept of gathering patient feedback, they pointed to several technical and cultural barriers to ePROs that CMMI should consider—and they asked who would pay the cost of gathering the data.

Monday’s listening session came after Friday’s surprise release of a 12-page request for information (RFI) for Oncology Care First (OCF), which would succeed the OCM, the 5-year experiment in payment reform that expires in 2021.

CMMI’s Christina Ritter, director of the Patient Care Models Group, kicked off the listening session along with Lara Strawbridge and Hillary Cavanaugh, who are working on developing OCF. Ritter described both the document and the listening session as an opportunity for oncologists and other stakeholders to have a glimpse at “what we’ve been thinking about internally.”

“This community is not shy,” Ritter said.

Oncology care groups have praised the multipayer OCM for transforming cancer care through greater focus on care navigation, palliative care, survivorship, and keeping patients out of the emergency department. But there are complaints that practices can be penalized for elements beyond their control—notably, the soaring cost of state-of-the-art immunotherapies that were not on the market when the OCM was conceived.

The successor model calls for 2 payment elements: the monthly population payment (MPP) and the performance-based payment (PBP):

• The MPP would consist of a management component, including enhanced services and evaluation and management (E/M), as well as an administrative component. The RFI document states that this payment would take patient mix and volume into account.
• The PBP would be evaluated against a target based on historical data, with adjustments for the participant experience and the use of new drugs.

Besides adding ePROs to the 6 practice activities currently required under the OCM, Strawbridge said other key updates include:

• Changes to definitions of attribution to make it more predictable at the outset of an episode; episodes will be attributed to the physician group practice as long as the participant bills at least 25% of the cancer-related E/M services.
• The trend factor, an adjustment that deals with drug costs, will occur at the cancer level rather than the practice level.
• Dropping low-risk cancers out of total cost of care responsibility.

Those who took part in the 3-hour session responded not only to specific items in the RFI but also to what they say is the head-spinning pace of payment reform; Ted Okon, MBA, executive director of the Community Oncology Alliance, urged CMMI leaders in his remarks and in a written statement to extend a November 25, 2019, deadline if the agency wanted thoughtful responses to the OCF proposal.

“It is completely unreasonable for oncology practices and stakeholders to adequately assess and provide detailed feedback on the OCF within the time CMMI has allotted,” he said. “Three weeks is too short a time for meaningful input.”

Okon noted that current OCM practices already face a December 3 deadline to decide if they are proceeding with 2-sided risk, and they face a host of new regulatory changes, including the mandatory Radiation Oncology Model, the final 2020 Medicare Physician Fee Schedule, and the Outpatient Prospective Payment System rules.

Gathering Patient Feedback Not Straightforward

Patients who are poor and live in rural areas may not be equipped to submit ePROs, according to some oncologists at the listening session. “Half of my patients still use a flip phone,” said Kashyap Patel, MD, of Carolina Blood and Cancer Care Associates, based in Rock Hill, South Carolina. Variations in socioeconomic status and transportation are real challenges, he said.

Barbara McAneny, MD, who treats patients in Albuquerque, New Mexico, agreed that no matter how hard practices try to prevent it, for patients without transportation, “the easiest way to get care is to call 911.”

These patients are not going to buy an iPhone or fill out a questionnaire, McAneny said. “Literacy is such an issue that it will require these practices to do this at the point of care,” and having staff members ask survey questions costs money. When her practice has surveyed patients, they often say, “Please stop doing surveys with us.”

And several speakers said the issue of integrating ePROs with existing electronic medical records remains unresolved.

It’s About the Drug Costs

Aaron Lyss, director of strategic payer relations at OneOncology, told the CMMI leaders that allowing physicians and care teams “maximum flexibility” was essential if they want add to reporting requirements under the OCF. “The more prescriptive that CMMI is, the more they constrain the innovation that we can all agree has been pretty remarkable.”

Lyss and 2 coauthors published a letter in JAMA Oncology calling on CMMI to take an entirely different approach in holding practices accountable. A future model should evaluate whether practices are following clinical pathways and require clinicians to document any deviation. “To avoid scenarios in which rigid adherence to pathways could devalue patient-centered considerations, we recommend that payers should expect only 80% of treatment decisions to be pathway adherent,” Lyss et al wrote.¹

McAneny, in her remarks, said the more she read the RFI, the more convinced she was that CMMI should embrace MASON (Making Accountable Sustainable Oncology Networks), the real-time alternative payment model she successfully presented to the Physician-Focused Payment Model Technical Advisory Committee, or PTAC.

But so far, CMMI has not moved forward on MASON, and the frustration that physician-driven payment models seem to be making little headway—despite promises to the contrary at the start of the administration—caused COA to do an about-face Monday.

While the RFI document states that OCF will be informed by the lessons of OCM as well as models presented at PTAC, Ritter was clear in her opening remarks Monday that when it came to a successor, “We really are looking at one model.”

Thus, after more than a year of discussion and buy-in from 6 pharmaceutical manufacturers, Okon’s statement included the announcement that COA will withdraw “OCM 2.0,” which it submitted to PTAC this summer.

“The PTAC process needs to be addressed, as it appears getting PTAC approval is not leading to CMMI funding,” Okon said in his statement. He called on policy makers to explore the MASON model and said the OCM 2.0 would continue “as a viable universal model not just for Medicare fee-for-service, but for all payers, including Medicare Advantage, insurers, and employers.”

Reference

Lyss AJ, Supalla SN, Schleicher SM. The Oncology Care Model—why it works and why it could work better [published online October 31, 2019]. JAMA Oncol. doi: 10.1001/jamaoncol.2019.4385.