Since July 2016, more than 170 oncology practices across the United States have been participating in the Oncology Care Model (OCM), the Center for Medicare & Medicaid Innovation (CMMI)’s 5-year pilot program designed to deliver higher quality, more coordinated oncology care at the same or lower cost. When practices elected to participate in the OCM, they knew they would eventually have to decide whether to accept 2-sided risk or leave the program, if a performance-based payment was not achieved.
Currently, the OCM is a 1-sided risk model. If a practice achieves a performance-based payment by the end of Performance Period 4, it can remain in the 1-sided risk model. If it did not earn a performance-based payment by August 2019, it must accept 2-sided risk or exit the program. Based on recent results discussed at the 2019 American Society of Clinical Oncology meeting, CMMI estimates that approximately 50% of the OCM practices may need to make a 2-sided risk decision this fall. There are many factors that practices should consider when deciding how to move forward with the OCM, and now is the time to begin thinking about this critical decision.
A Closer Look at 2-Sided Risk
Last fall, OCM administrators presented an alternative 2-sided risk model that is less onerous than the original version, which had a big upside for practices if they performed well but carried a huge stop-loss if they did not achieve performance goals. The original performance ceiling was 20% of total cost, which was also the percentage of downside risk.
The concern was that some practices would have issues providing care if performance goals were not met and they would have to return a large amount of money. Consequently, CMMI developed the alternative payment model (APM), which caps the downside at 8% of practice Medicare revenue and external drug revenue, while keeping the upside slightly less than the original model. This is a vast improvement over the original version.
Another significant benefit is that the new version provides a neutral performance zone, where practices neither achieve nor owe additional payments. This is a safety zone for practices that are saving Medicare money but have not yet done well enough to earn a performance-based payment. For some practices, staying neutral is more attractive than dealing with the possibility of returning dollars, so many may choose this new alternative 2-sided risk option.
Smaller Practices May Opt for 1-Sided Risk
Smaller practices face unique challenges when deciding how to move forward with the OCM. Some did well in the beginning and earned a performance-based payment but are now experiencing volatility that could affect their ability to earn shared savings. By definition, small practices have fewer patients than large practices, but if their patients have high treatment costs in a 6-month performance period, this could have a negative impact on their performance. Some smaller practices in the US Oncology Network that have achieved a performance-based payment and maintained it through August 2019, will most likely stay 1-sided because of the unpredictability of their patient base.
OCM Data Points Actionable
Practices participating in the OCM have a wealth of data at their fingertips provided by CMMI and captured to meet program requirements. Analyzing these data for quality results and cost trends over time can help them decide how to proceed with the OCM, as well as identify areas for improvement.
Our network practices that are confident about continuing with the OCM have consistently done well on their quality scores, and many have seen the score rise, increasing their performance-based payments. Their cost trends have also improved consistently, with little volatility. Once a practice starts getting a performance-based payment, if it maintains that performance, it will continue to get a payment judged against its established baseline and trend factors.
But many practices are still looking for a path to success. Before they decide about exiting the OCM, they should analyze their data to see what they could improve that would significantly affect their performance and costs. Practices can also judge how they are doing by looking at the quarterly reports from CMMI that identify OCM trends. This can help them see how their costs compare with other practices and identify potential opportunities for cost-savings.
Because the cost component of the OCM is critical, practices should pay close attention to their cost data, while improving quality, and partner with analytics experts, to know where opportunities exist. The US Oncology Network is holding total cost workshops with actionable analytics from the program outcomes and analytics team to help practices identify improvement opportunities. Practice data regarding hospitalizations, emergency department visits, drug utilization, and advance care planning are examined closely to pinpoint areas for improvement.
Preparing for 2-Sided Risk
Practices that are considering a transition to 2-sided risk can focus on a few activities now to help gauge their level of potential success and risk, including whether they would be required to pay back money, receive a performance-based payment, or land in the neutral zone. They can also examine how they are trending over time.
The maximum stop-loss would be to determine what a worst-case payback would entail. Those concerned about paying back dollars should identify ways to minimize the financial impact should that happen. One approach is to self-insure against the downside. Residual funds from the Monthly Enhanced Oncology Services payments could be used to supplement, if necessary. Practices that achieve an advanced APM bonus of +5% of their Medicare allowable could also use these funds to self-insure.
Some practices are seeking catastrophic coverage from an insurance company to shield against downside risk. Our network is working on this option with several practices, but few insurers are offering this coverage, and for those that do, the premiums are high initially because of the uncertainty involved.
Practices should continue to look for ways to provide the best quality of care at a sustainable cost. Examine drug initiatives, enhanced services, emergency department utilization, hospitalizations, advance care planning, and other activities that substantially affect cost and the patient experience. Also ensure that providers and staff are heading in the same direction and looking for ways to continue improving. It is also important to identify outliers and deal with them. Practices should also identify future opportunities to maintain high performance on quality outcomes and costs, ensuring that patients and care teams see the value in the program.
Exiting the OCM
By October 3, 2019, practices should have decided if they plan to exit the OCM or select 2-sided risk, if required. Since the program is an APM, practices leaving still have APM status for the remainder of this year and must continue to submit required data and documentation.
Once practices leave the program in January 2020, they will be participating in the Merit-Based Incentive Payment System (MIPS), another Medicare program that covers all specialties, not just oncology. MIPS is a 2-sided risk program, but the upside and the downside are lower than the 2-sided OCM. Practices transitioning to MIPS are not abandoning value-based care, they are just switching to a broader program. They still need to focus on quality measures, improvement activities, and cost.
One of the concerns about MIPS is that it is not an oncology-specific program. Patients with cancer are often sicker and costlier to treat than patients in other specialties, so there is concern about how MIPS will evaluate oncology.
The Future?
The big question facing practices staying in the OCM is what happens after 2020 when the program ends. Will it remain as it is today, or will it change to a bundled payment system or a completely different model?
The OCM is a significant step forward in cancer care. My hope is that it will continue long into the future, and if it does change, that it will not lose sight of patient experience and quality outcomes.
