Uncertainty From COVID-19 Delays Progress on the Road to Value-Based Cancer Care

https://doi.org/10.37765/ajmc.2020.88565

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Coronavirus disease 2019 (COVID-19) has had catastrophic effects on all aspects of health care, including cancer care. Oncology practices, just like all health care providers, have focused on reorganizing their operations to adjust to the changes driven by the pandemic. Providing a safe and protected environment for both patients and employees during a worldwide pandemic has become the number-1 priority over the past several months. While quality care is still being delivered to

patients with cancer during this chaotic time, it is fair to say that continued practice transformation to meet value-based care initiatives has not been top-of-mind. Indeed, COVID-19 has had a dramatic impact on the significant progress being made regarding value-based cancer care, adding uncertainty and postponing the introduction of new reimbursement models. With no quick fixes on the horizon to prevent or cure COVID-19, the pandemic will linger. Although some bandwidth previously dedicated to advancing value-based care may have been momentarily absorbed by the pandemic, that does not mean value-based care should be forgotten. Providers still must think about value. With the initial emergence of the virus in the rear-view mirror, it is time for practices to consider how value-based care can work in and around disruptions caused by the pandemic.

COVID-19’s Impact on the Oncology Care Model
COVID-19 has created a significant distraction from normal practice operations. Real transformation to value-based care and performing at a high level in the Oncology Care Mode (OCM) takes time, energy, and dedicated resources, and that focus can be easily blurred when dealing with a pandemic.

The uncertainty that comes along with the pandemic is a huge worry. The OCM is a very detailed, complex model that requires a predictable environment in which practices have control. It is built around the concept of baseline practice patterns and measuring quality and cost metrics over time. However, comparing performance during this crisis against performance in a normal year is problematic. Another major element of the OCM is data collection and reporting. These activities require time and resources, much of which have been diverted to COVID-19 response. Expecting practices to have improved outcomes while spending less in the middle of a pandemic is simply not a realistic goal.

COVID-19 has greatly altered the landscape, making it very difficult—if not impossible—for practices to predict and control what happens to their patients. Cancer providers are well aware of the disruption the pandemic has caused when it comes to delivering care. A recent survey of cancer patients and survivors verifies what was already suspected¹:

1. 51% of all respondents reported some impact on their care due to the virus.
2. Of those whose care was affected, nearly 1 in 4 reported a delay in care or treatment. The most common delays included:
• in-person provider appointments (50%);
• imaging services to see if a cancer had grown or returned (20%); and
• supportive services, such as physical therapy or mental health care (20%).

Some surgical procedures have been classified as nonessential and, therefore, postponed; this has been especially true of diagnostic procedures. Unfortunately, this can delay the start of treatment, and with some aggressive cancers, a delay of just a few weeks can negatively influence outcomes. This, in turn, can affect performance in the OCM. Some patients are canceling appointments because they are fearful of being exposed to the virus. These patients are not getting the care they need, and many will end up in the emergency department or the hospital. Others may not even be able to get to the hospital when it is necessary, so their condition worsens at home. These situations, which greatly increase the cost of care, have an impact on performance in the OCM.

Adjustments Made to the OCM in Response to COVID-19

The US Oncology Network (The Network) and other stakeholders have been working hard over the past several months to inform the Center for Medicare and Medicaid Innovation (CMMI) about the interruption to patient care that COVID-19 has caused and how it might impact OCM results. There is a strong likelihood that COVID-19 could disadvantage practices beyond their control. Many are operating under the 2-sided risk option and may have to return funds if expenditures are higher than benchmark.

Fortunately, CMMI has been receptive, and it recently announced adjustments to the OCM for performance periods affected by the COVID-19 public health emergency (PHE). The adjustments pertain to financial methodologies, quality reporting, and model timelines. To the credit of CMMI, these relief options add greater flexibility to the program and will be an enormous help to practices that want to remain in the OCM but are concerned about their results due to the pandemic.
On June 3, CMMI announced these changes²:

Payment methodology
1. Practices in the OCM can elect to forgo upside and downside risk for performance periods affected by the PHE.
2. OCM practices that remain in 1- or 2-sided risk for the performance periods affected by the PHE will have COVID-19 episodes removed from reconciliation for those performance periods.

Quality reporting
1. Aggregate-level reporting of quality measures and beneficiary-level reporting of clinical and staging data are optional for the affected periods.
2. The requirement for cost and resource utilization reporting and practice transformation plan reporting in July/August 2020 is removed.

Timeline
1. The OCM is extended for 1 year through June 2022, allowing for a delay of the Oncology Care First (OCF) model.

The Network is pleased that CMMI recognized the concerns that were raised, then took action. Although we are several months into the pandemic, the impact on practice performance in the OCM is still unknown. Consequently, the adjustments that provide some flexibility, particularly concerning downside risk, are greatly appreciated.

OCF Details Are Sketchy but Concerning

The launch of the OCF model has been postponed for at least a year due to the pandemic. This is in line with a request made by The Network and a number of other stakeholders. We felt that extending the OCM was important, as practices in The Network were worried about rapidly transitioning into a new model during this chaotic time. Out of anxiety caused by the uncertainty of the pandemic, practices would be reluctant to participate in a new model that might add even more unpredictability. A lack of participation would not be in the best interest of either the practices, who want to lead the way in payment reform, or CMMI, which has a vested interest in ensuring that value-based care models evolve and succeed.

A year from now, if some sort of normalcy has not returned, practices may still have reservations about participating in the OCF. Whether they are willing to take on this new voluntary model will largely depend on what remnants of the pandemic still exist. If the virus is still widespread, practices will likely be hesitant to take on more risk, particularly if the way they must manage risk is not clearly defined.

CMMI may choose to hold off launching the OCF until the PHE is completely over, although its leaders are anxious to shift away from the OCM to a model with an approach that focuses more on bundled payments. If CMMI proceeds while the pandemic is lingering, many aspects of the program will need a second look. Must COVID-19–positive patients be factored into the equation, or not? Obviously, proceeding while the virus is still present would add to the complexity of developing and managing the model. The PHE would drastically change the model CMMI originally envisioned.

Practice-level decisions about whether to participate in the OCF will ultimately depend on what the model looks like. All that is known so far comes from a preliminary 12-page document that is limited on details and difficult to fully and accurately assess. However, from this brief information, practices across The Network have expressed concerns. Consequently, we offer the following suggestions to CMMI on how the model could be improved:

1. Provide greater transparency into the calculation of the OCF baseline, benchmark,and trend factor;
2. Improve transparency of the Monthly Population Payment (MPP) methodology and provide practices with an estimate of the MPP prior to application;
3. Provide more data on a real-time basis to improve both patient care and physician satisfaction with the model;
4. Allow all participating practices to start with 1-sided risk and continue through at least 2 full performance periods before deciding whether to continue as 2-sided;
5. Allow OCF practices that are participating in 2-sided risk the ability to opt out of other
CMMI demonstration models if there is a clear conflict in model scope; and
6. Allow another opportunity for stakeholder feedback after more details of the OCF model have been released.

We are hopeful that CMMI will consider our suggestions, as over the past several years, the agency has been very collaborative in dealing with issues surrounding the OCM. On a number of occasions, they have listened to our concerns and made significant adjustments that improved the model.

They deserve credit for their willingness to seriously consider our input, and, hopefully, they will take this same approach when building out the OCF. Practices will be more likely to participate if they feel their voices have been heard.

Value-Based Cancer Care in the Time of a Pandemic

While COVID-19 may have interrupted progress on the road to value-based care, practices need to continue delivering high-quality, high-value care through value-based models—even if the pandemic persists. It can be done. Across The Network, OCM practices are circumventing obstacles created by the virus by using personal protective equipment, Plexiglas shields, social distancing, and new policies to protect patients and staff. Furthermore, The Network practices readily employed telehealth to stay connected with patients but to minimize exposure to others in busy clinic settings. This strategy is working, as infusion volume is down less than 5%, and radiation volumes, although decreased, are down less than predicted.

Shying away from value-based care in turbulent times is not the answer, as value-based care is not going away. We know the CMS is strongly committed to transforming the health care landscape away from fee-for-service, and the models we are seeing now are simply stepping stones to the future. The OCF delay is merely a temporary interruption in the path forward. Looking ahead, the need for value-based care will only become more important and urgent as the government looks for ways to recoup the trillions of dollars spent on the COVID-19 response. Arbitrary cuts can be imposed, but the more thoughtful way is to pursue reimbursement models that incentivize good care but do so in a value-based manner that promotes buy-in from the physician community. Hopefully, common sense will prevail.

The OCM is an example of a successful value-based program in oncology. It attempts to drive
genuine transformation in how cancer care is delivered to Medicare beneficiaries by incentivizing practices to provide more comprehensive, cost-effective care. The 15 practices in The Network that are participating in the OCM have greatly enhanced their patient care. For example, OCM patients receive comprehensive care management and treatment plans, assistance from navigators and social workers, advance care planning, survivorship advice, information on estimated total out-of-pocket costs, and enhanced team care.

Across The Network, these reforms and investments have:
1. reduced hospital admissions by 7%;
2. reduced emergency department visits by 4%; and
3. driven a 5% increase in hospice stays longer than 3 days.

A key component of this success is adherence to evidence-based Value Pathways powered by the National Comprehensive Cancer Network, which have been proven to lower the overall cost of care with equal or better outcomes.³ Collectively, The Network practices alone have realized more than $80 million in savings for Medicare through participation in the OCM, while being able to appropriately manage all aspects of care delivery, including drug utilization. Many practices have also shared in the cost savings provided by delivering high-value care, helping them maintain financial stability in the challenging health care landscape.

Commercial Payers Can Help Drive Value-Based Care

As an integral component of the health care system, commercial payers are playing an important role in responding to COVID-19. They must keep up with the evolving needs created by the pandemic. Once the PHE has passed and the dust has settled, we are hopeful they will follow the lead of CMS in driving and participating in value-based cancer care. In the past, commercial payers have expressed an interest in value-based models, but legacy claims systems designed around fee-for-service make it difficult for commercial payers to implement bundled case rates or episodic payment structures.⁴ Hopefully, payers and providers can collaborate to build value-based arrangements.⁴

Generally what works for Medicare can successfully be pursued by commercial payers. This
approach would help avoid some of the draconian measures upon which payers often rely to control costs, such as expanded prior authorization, utilization management, restrictive formularies, and fail-first/step-therapy policies. The cost savings they are seeking can be achieved through value-based care, while also providing a more patient-friendly experience that recognizes the critical role physicians play in delivering quality care.

Flexibility and Collaboration Are Critical for Value-Based Care Success

Over the past several years, great progress has been made in transitioning cancer care to value-based models. While COVID-19 has created many challenges, providers are working around the obstacles, getting back into the rhythm of delivering high-quality, value-based care. CMS has set a goal of increasingly tying reimbursement to value, and the pandemic has not diminished the desire to reach this objective. Consequently, we must keep moving forward despite the pandemic, so the significant progress made so far is not lost.

Value-based care works best in a predictable setting where practices have control over outcomes, but unfortunately, COVID-19 has added an enormous layer of uncertainty. Providers are patiently waiting to see what the true impact of the pandemic is, especially concerning patient behavior patterns and other factors that directly impact performance in value-based models. The US Oncology Network encourages CMMI to continue to maintain an open dialogue with providers. Value-based care in today’s ever-changing landscape can only succeed with high levels of adaptability, collaboration, and continuous stakeholder engagement.

Author Information

Neubauer is the chief medical officer of The US Oncology Network in The Woodlands, TX. Jones is the US Oncology Network’s vice president of government relations and public policy.

References

1. Survey shows COVID-19 pandemic is affecting patients’ access to cancer care. ASCO Post. April 21, 2020. Updated April 30, 2020. Accessed August 26, 2020. https://ascopost.com/news/april-2020/survey-shows-covid-19-pandemic-is-affecting-patients-access-to-cancer-care/

2. CMS Innovation Center models COVID-19 related adjustments. CMS. June 3, 2020. Accessed August 26, 2020. https://www.cms.gov/files/document/covid-innovation-model-flexibilities.pdf

3. Neubauer MA, Hoverman JR, Kolodziej M, et al. Cost effectiveness of evidence-based treatment guidelines for the treatment of non-small-cell lung cancer in the community setting. J Oncol Pract. 2010;6(1):12-18.doi:10.1200/JOP.091058

4. Miller J. 4 ways to adapt to new oncology value-based models. Managed Healthcare Executive. November 4, 2019. Accessed August 26, 2020. https://www.managedhealthcareexecutive.com/view/4-ways-adapt-new-oncology-value-based-models.