Will a Payer—Provider Collaboration Guarantee OCM Success?

The Oncology Care Model (OCM) is in its infancy right now, but participating practices have been preparing for its implementation for several months. Following the launch of the pilot phase, and as practices and payers start accruing data, identifying the keys for success becomes vital. At the Payer Exchange Summit V, sponsored by the Community Oncology Alliance, oncologists and payers came together to discuss the role of collaboration and data sharing for the successful implementation of the OCM.

Participating on the panel was Bruce Gould, MD, medical director, Northwest Georgia Oncology Centers; Terrill Jordan, president and chief executive officer, Regional Cancer Care Associates (RCCA); Bhuvana Sagar, MD, medical director, Cigna; and Maria Sipala, director, strategic planning, Aetna.

Speaking about the extent to which payers and providers can collaborate on OCM, Gould said, “[They] are working together, but they need to identify each other’s limitations. It’s a Herculean task to pull actionable data out of the haystack, and it requires that we keep those lines of communication open.”

“Both [payers and providers] ultimately want the same thing…we want to do the right thing for the patient,” said Sagar. “We as payers try to understand where the practice is coming from—we try to have conversations with providers over time and its almost about building the trust,” she added. Despite the efforts to marry what is important for the 2 stakeholders, Sagar acknowledged that there are limitations and challenges.

Jordan said that earlier they were in a constant battle with payers, “But that has changed now. While understanding the data is key to improving outcomes, payers do not know everything,” he said. Jordan believes that the road to better healthcare outcomes and improvements in care delivery is via understanding the data at hand and asking the right questions.

Explaining the need-based progress in data mining by Aetna, Sipala said, “A few years back we had the metrics, but we lacked in tools needed to scour through the data. That’s when we developed the necessary tools. So now we have the metrics, the tools, and we are sharing it with the providers. But we are still not where we need to be.”

Preparing for Implementation

Several clinical practices have worked out different payment models with health plans, some of which can inform participation in the OCM. One such model is "COME HOME," which was developed by New Mexico Oncology Hematology Inc. “We have had processes in place from COME HOME and for the oncology medical home, so we did not need too much work to adapt to private payer models,” said Gould. “When we started promulgating the OMH concept, the common message was already out there, with slight variations in the theme.” He added that while the program looks similar across all payers, differences might arise in what we get back from the payers, and “How we interpret it and then act on it might be the challenge.”

Speaking about Cigna’s Collaborative Care program, Sagar explained that when the program expanded to oncology, it continued to work on risk adjustment and reporting. “We have, however, tried to align with the OCM at least on quality measures that made sense for our patient demographic. We have tried to make it easy for the groups to transition to our model. But there have been challenges,” she said. “The bottom line is to work toward keeping the costs low and improving outcomes.”

Jordan explained that for RCCA, which was not a part of COME HOME, they had to start with the basics. “We needed significant infrastructure changes. We also looked at the program and we spoke to our payers to look at our model and critique it for us. This allowed us the flexibility to tweak the model before implementing it in the clinic,” Jordan said. He acknowledged that the payers they worked with were very accommodating and flexible, because they realized that the successful implementation of the model depended on this collaboration.

So what are some of the prime items needed for practice redesign and how can they be prioritized?

At RCCA, there were 2 main buckets of changes, said Jordan. The first was changes within the administrative structure, including changes with respect to value, quality, and cost, in addition to the need for care coordination. “The second was improving things that we were already doing in the clinic, but doing them better, so looking at it from a different lens. With respect to physician engagement, it was imperative to not change their workflow, or at least find common ground and include them into discussions on why those changes were important,” Jordan said.

Sagar pointed out the importance of ensuring an adequate cancer care team, as well as knowledge sharing. “Exchange of ideas is critical for practice improvement,” she said.

Sipala agreed and added that, as a payer, they have significant access to resources, which may not always be available to providers, particularly the smaller practices. “So we need to understand where they need assistance.”

Sagar told the audience that payers seek a better understanding of the clinical data to understand the cost of care distribution for a practice. “We need to stratify this data. We need the details to understand the potential source of cost savings for the practice. With oncology, there are so many different cancer types and different staging for the same cancer. And add to that the complexity of regional differences.”

Sagar and Sipala agreed that identifying actionable data is very important—data that can feed back into the clinic and help make improvements.

Providers seek data as well. “Practices need more information on benchmarks that they need to meet to be able to bring about practice improvement,” Gould responded.