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We Need Better Quality Measures for Oncology Care First
The Centers for Medicare & Medicaid Services Innovation Center (CMS/CMMI) is proposing to build on the Oncology Care Model (OCM) with a new value-based oncology payment model called Oncology Care First (OCF). As proposed, OCF will largely retain the OCM structure and requirements for practice redesign (ie, the OCM care transformation standards) and the current OCM quality measures. If the OCF is adopted as proposed, CMS will be missing a critical opportunity to advance quality measurement for oncology care by not addressing important gaps in the OCM quality measure list.
CMS utilizes clinical data and quality measures to assess care improvement and clinical outcomes for Medicare beneficiaries. The OCM quality measure list initially included seven cross-cutting measures (across all patients, including all cancer patients) and five cancer-specific measures focused on breast, prostate, and colon cancers. After the second year of OCM, CMS retained the cross-cutting measures (such as all-cause hospital admissions and ED visits), but discontinued use of the cancer-specific measures due to issues with care attribution, clinician burden of reporting, and small denominator sizes. An example of a cancer-specific measure is: Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under age 70 years with AJCC T1c, or Stage II or III hormone receptor-negative breast cancer (Commission on Cancer/ American College of Surgeons). The cancer-specific measures that were in the original OCM measure list have been in use for several years and may have been topped out, meaning that the performance rates are very high and there is little variation in performance across practices. Furthermore, some of the current measures in the OCM measure list, such as Plan of Care for Pain, are considered “check-box” process measures akin to standards, and do not afford clinicians the opportunity to take action for quality improvement.
CMS and other payers administering value-based payment models need to drive quality forward by implementing quality measures that are clinically relevant, actionable, and meaningful to the affected practices and their patients. Specifically, the OCF presents an opportunity for CMS to test or implement new measures in critical areas of oncology care, including patient-reported outcomes (PROs), guideline adherence, novel therapies, and focus on the most prevalent cancers (ie, breast, lung, prostate, and colorectal) in the Medicare population.
Patient-Reported Outcome Performance Measures
Cancer diagnosis and treatment can create significant psychological distress, physical functioning deficits, and quality of life burdens for patients and their families. Research indicates that using Patient-reported Outcomes Measures (PROMs) is associated with improved symptom control, increased supportive care measures, and high patient satisfaction. The use of PRO performance measures (PRO-PMs) encourages clinicians to use PRO tools to manage problematic symptoms and functional deficits that arise during the course of cancer care. CMS has proposed to include a new practice redesign element in OCF that would require reporting electronic PRO (ePRO) data. CMS should include complementary PRO-PMs in the OCF measure list to reward clinicians for documenting assessment of functionality and outcomes of symptom management. CMS should consider leveraging existing PRO performance measures (PRO-PMs) or those in development—such as the Pacific Business Group on Health’s (PBGH) health-related quality of life and pain measures that are being developed under MACRA funding for MIPS—or cancer symptom control outcome measures for pain, nausea, and constipation recently implemented by Minnesota Community Measurement (MNCM). Other PRO-PM measure concepts CMS should explore include care concordance with established patient goals and shared decision-making for treatment selection.
Guideline-Concordance Measures
The use of evidence-based care is important to patients, employers, and payers, and guideline-concordance measures allow these stakeholders to compare clinician adherence to guidelines. OCM and OCF include guideline adherence as a practice redesign element, but neither include related quality measures in their measure lists. CMS should explore opportunities to connect compliance with the practice redesign activity to quality assessments addressing clinician delivery of evidence-based care. One word of caution is that the development and testing of guideline concordance measures may be difficult due to the multiple stages and grades in each type of cancer, some of which may require unique measure exclusions. In addition, regular maintenance of guidelines would require regular measure updates. However, having valid and reliable guideline-concordance measures would likely be game-changing for patients.
Measures Addressing Novel Therapies
The landscape of drug and other therapies is evolving rapidly, and novel treatments introduce new considerations for quality measurement. Examples include management of immune-related adverse events, coordinating administration of novel treatments such as chimeric antigen receptor T-cell therapies, and monitoring of adherence to oral therapy for non-infused drugs. CMS should consider how recently developed measures, such as the Oncology Nursing Society’s (ONS) measure for management of immune-related adverse events associated with immune checkpoint inhibitors could be integrated into the OCF measure list. Furthermore, payment models that incentivize cost containment may lead to the unintended consequence of underuse of costlier novel therapies, as clinicians are concerned that the use of appropriate but expensive therapies—including immunotherapy or oral drugs—may result in financial penalties under value-based payment models.
Focus on the Four Most Prevalent Cancers
In a recent Health Affairs blog post, de Brantes et al recommended that CMS narrow the focus of OCF to the four most treatable and prevalent cancers in the Medicare population: breast, prostate, lung, and colorectal. This would target resources toward the largest opportunities to reduce variation in cancer treatment. Predictability in clinical and financial outcomes would also be enhanced because the numbers of patients are well-known and clinical pathways are well-established for these types of cancer. There are several measures related to novel therapies and outcomes (eg, survival and disease progression) for the four most prevalent cancers that could be included in the OCF quality measure list. Implementing these measures would align with the recommendations above to include measures addressing guideline adherence and novel therapies.
Conclusion
The advent of the second oncology payment model demonstration, OCF, provides CMS the opportunity to implement clinically meaningful and actionable measures that are important to clinicians and their patients. We recommend that CMS consider adding measures related to PROs, guideline adherence, novel therapies, and the most prevalent cancers to enhance the proposed OCF measure list.
What do you believe is the one most important measure gap in OCM? What measure concept would you propose for OCF to fill that gap? Please comment below.
About the Quality Outlook Commentary Series
Breakthrough treatments in cancer care, including precision therapies tailored to specific patient factors, are driving rapid changes in the definitions of oncology quality and value. Efforts to implement value-based care models in oncology must meet the demands of evolving science, new best care practices, and shifting patient priorities. Quality measures must be up-to-date and relevant. Payment models must recognize the challenges and costs of managing complex patient populations with diverse needs. In this JCP blog series, Quality Outlook, Discern Health, part of Real Chemistry, will explore key issues in oncology quality and value through posts focused on measurement, value-based payment, and quality improvement.
About Tom Valuck, MD, JD
Tom Valuck is a Partner at Discern Health, part of Real Chemistry. He is a thought leader on health care system transformation and helps lead the firm’s focus on achieving better health and health care outcomes at a lower cost. Tom’s work at Discern, part of Real Chemistry, includes facilitating the exploration of next-generation measurement and accountability models for health care delivery systems. He also helps clients develop strategies to achieve success within the value-based marketplace.
About Manasi A Tirodkar, PhD, MS
Manasi A Tirodkar is a Director at Discern Health, part of Real Chemistry. She brings a wealth of knowledge and experience in health services research, quality measurement, and practice transformation in primary and specialty care settings. Prior to joining Discern, Manasi was a Lead Research Scientist at the National Committee for Quality Assurance (NCQA) for more than 10 years. At NCQA, she led measure development projects spanning various disease conditions and populations, including oncology.
About David Blaisdell
David Blaisdell, a Director at Discern Health, , part of Real Chemistry, leads and manages client projects, providing insight and subject matter expertise, particularly on quality landscape analyses and measure gap identification. David has led and contributed to projects focused on oncology quality measurement to identify key gaps in measures used in accountability programs and opportunities for measure development. Through this experience, David helps clients navigate measurement and value-based payments and define strategies for success.
About Discern Health
Discern Health, part of Real Chemistry, uses research and strategic advisory services to help our clients improve health and health care through value-based payment and delivery models. These models align performance with incentives by rewarding doctors, hospitals, suppliers, and patients for working together to improve quality while lowering total costs. Real Chemistry is an independent provider of analytics-driven, digital-first research, marketing services, and communications to the healthcare sector.
