Value Transformation: Observations on Performance Periods 1-5 Evaluation Report of the Oncology Care Model

J Clin Pathways. 2021;7(5):28-32. doi:10.25270/jcp.2021.06.00003

The Centers for Medicare & Medicaid Services (CMS) announced another evaluation report of the Oncology Care Model (OCM) in January 2021,¹ covering activities and results for performance periods (PPs) 1 through 5 of 11. In the March 2019² and September 2020³ editions of this journal section, authors offered observations based on the previous OCM annual reports.This current article builds upon those observations in light of data from this most recent report published in January 2021, focusing on Medicare spending as well as other performance measures related to the patient experience, management of depression and pain, emergency department (ED) and hospital use, end-of-life (EOL) care, and medication utilization and selection. Insights gained from this performance evaluation have potential applicability to the transformation of oncology and other specialty practices as well as primary care. OCM practices continue to evolve, and their value transformation efforts assume a new sense of urgency in an era of pandemic care. 

The 6-year OCM has focused on delivering high-quality cancer care while controlling costs by improving care coordination and access to care for Medicare beneficiaries receiving chemotherapy for cancer within 6-month episodes, which are grouped into 6-month PPs based on episode start dates. This model will operate for 11 consecutive PPs leveraging a two-pronged financial approach to incentivize high-quality care: a per-beneficiary $160 Monthly Enhanced Oncology Services (MEOS) payment, and the potential to earn performance-based payments (PBPs) for meeting Model quality and cost goals. This report examines the first five PPs for episodes that began in mid-2016 and ended by July 2019.  

In this report, Medicare’s total episode payments (TEPs) increased rapidly in both OCM and comparison episodes; however, it rose $297 less (P<.05) in OCM episodes, representing 1% of baseline payments.¹ Overall, OCM had a positive impact on TEP (particularly for certain higher-risk episode types); however, when model payments from PP1-4 were included (MEOS and PBP), OCM resulted in net losses for Medicare. This report also focused on other important measures such as the patient experience, management of depression and pain, ED and hospital use, EOL care, and medication utilization and selection as well as other measures to evaluate the evolution of OCM.⁴

The Patient Experience

The OCM assessed patient care experiences and the overall ratings of the cancer care team through two different lenses: directly, via a patient survey, and indirectly, through case studies and the information practices report to CMS about their efforts to identify and manage pain and depression. The survey evaluated 6 composite patient experience scores including access, effective communication, enabling patient self-management, exchanging information, shared decision-making, symptom management, and also included a question about the respondent’s overall rating of the cancer care team. The results showed that the OCM had no impact on any of the 6 patient-reported composite measures of care experience, but this was not a negative finding because most of the composite measures had been rated quite highly by respondents in both the OCM and comparison groups at the start of the Model (averaging 9 on a 10-point scale), and ratings did not change over time. A few areas of opportunities for improvement were observed including shared decision-making, enabling patient self-management, and symptom management. The OCM also led to small but significant declines for Hispanic respondents on the 6 survey composite measures except symptom management, ranging from -0.5 (on a scale of 0–10) for the access to care composite to -1.0 for the effective communication composite as well as a small decline of 0.4 in overall satisfaction in patient-reported care experiences with cancer care.¹

Further Opportunities

To further improve the patient care experience, addressing the three areas of opportunity (ie, shared decision-making, enabling patient self-management, and symptom management) would be a great start. For example, in one of the OCM practices, a shared decision-making appointment was established to improve the patient experience. This appointment had a nurse navigator join a patient and their oncologist to discuss treatment options, documented the options jointly reached by the patient and the oncologist, then a copy was given to the patient (and a copy was put in the chart). For practices with Hispanic populations, areas that had lower scores in the 6 composite domains should be evaluated and, where possible, involve patients in the change process to further improve the care experience.¹

Management of Depression and Pain

Depression contributes to higher rates of suicide, and pain is a common cause of ED and hospital utilization among oncology patients.² Consistent screening and management of depression and pain may improve quality of care and decrease overall health care use.¹

As of PP5, the OCM Clinician Survey¹ data indicated that the mean practice-reported performance rate for depression screening and management was 70.3, an improvement over PP2 (57.2; P<.05). Nevertheless, although OCM patient survey respondents reported improvement (baseline=53.4%; year 3=58.3%; P<.01) in their care team discussing a respondent’s emotional problems with them, no improvement was found in addressing those needs. Among those reporting emotional problems, at both baseline (74.9%) and year 3 (73.9%) about three-quarters of respondents with emotional problems reported that their cancer care teams tried to address those needs, leading one to conclude that about a fourth of respondents with emotional problems did not perceive their emotional problems were addressed by their cancer care teams. Some practices also separately screened for psychosocial conditions and expressed concern about inadequate community resources to address identified needs. While practices self-reported relatively high and improved pain assessment and management rates (PP2=77.2; PP5=86.6; P<.05), there was no change over time in OCM patients reporting that their practices discussed and addressed their pain. For those patients who discussed pain, however, in year 3, most reported care team efforts to help them (93.2% overall and 95.6% for patients with higher risk episodes), suggesting that when discussed, intervention is forthcoming. 

Further Opportunities

Regarding pain, many practices may reasonably consider shifting to sustaining their gains, particularly since patients indicated high levels of assistance when pain was discussed. Regarding depression and other emotional problems, with ~30% of OCM practices not reporting depression screening/follow-up, and more than 40% of patients reporting no discussion with  their OCM teams regarding emotional problems, opportunities remain to adequately address depression and other emotional concerns. Further, about a fourth of patients who did report emotional problems did not perceive that their cancer care team addressed their emotional problems, and some practices screening separately for psychosocial conditions noted insufficient resources to address identified psychosocial needs. Time pressures, inadequate clinician training,⁵ depression/oncology care fragmentation,²  and insufficient referral resources are common barriers to depression screening and assistance. The Joint Commission⁶ published a study listing four successful core interventions for increasing depression screening and care, including use of: multilingual screening tools; shared decision-making tools (eg, The Option Grid^TM); follow-up tracking logs; and team meetings/in-services to expand capacity. Through assessment of cancer patients’ care experiences, McGill University has identified emotional support as the greatest unmet need and is piloting a program to understand the potential capacity-building benefits of integrating trained Patient Advisors (with lived experience of cancer) into cancer treatment teams.⁷ Strategic focus on access, analytics, and amplification may offer patients additional emotional support, and Hennessey and Mamidi (2021)⁸ describe pertinent steps that payers, providers, and pharma manufacturers can take.

ED and Hospital Use

The OCM has emphasized the timely access to care, patient navigation, close monitoring of high-risk patients, and care coordination to avoid ED visits and hospital use. As of PP5, the OCM had no statistically significant impact on payments for ED visits, acute care hospital, intensive care unit admissions, or 30-day unplanned readmissions. There was a slight but not clinically meaningful impact on hospitalizations resulting from chemotherapy-related toxicities; however, the OCM did see statistically significant fewer hospitalizations at EOL compared with patients in comparator practices. 

Further Opportunities

The similar decline in OCM and comparator practices may have been due to other pressures and programs, unrelated to the OCM such as the Medicare hospital readmission reduction program, which emphasizes the prevention of unplanned readmissions. As OCM practices continue to strive to improve ED visit utilization—in addition to relying on expert assessments by nurse navigators, care coordinators, and oncologists to identify patients at a higher risk for ED visits—leveraging algorithms and tools to standardize the identification of potential patients at higher risk for ED visits may be of benefit. For example, an academic practice created an algorithm to identify patients likely to visit an ED. It incorporates diagnosis, toxicity of chemotherapy, comorbidities, social supports, and demographic/social factors, as well as past ED utilization. This may result in a consistent and effective process to support this OCM goal.

EOL Care

Evaluators¹ reported that many OCM practices attempted to improve EOL care by enhancing palliative care access and encouraging advance care planning. These interventions may have contributed to a slight decline (1.1 percentage point; P≤.05) in last month of life hospitalizations for deceased OCM patients, compared with their comparison group, with an associated decline in TEP payment ($539; P≤.05). This decline in EOL hospitalizations was noted in the previous annual report for PP1-3,¹ suggesting that gains had been sustained through PP5. Decreased EOL hospitalizations did not appear to impact perceptions of surveyed family members of deceased patients, who indicated that deceased patients received good EOL care before and after the OCM began, with no differences noted between OCM and comparisons. It is noteworthy that, although interviewed practices report earlier and more hospice referrals since the OCM model launch, the evaluators noted that no OCM impact was found on hospice use, duration, or timing.¹ Further, in surveys of family members of deceased OCM patients, the percentage of providers reported to discuss hospice with patients and families appears unchanged¹ (baseline mean=83.18; intervention mean=83.79). These data suggest that opportunities continue to exist to increase hospice discussions to expand appropriate use, timing, and duration of hospice care.

Further Opportunities

Barrier analysis and multipronged, targeted interventions have the potential to advance hospice discussions. Evaluators¹ of interviewed OCM practices described health system, clinician, and patient-associated barriers to earlier and more frequent hospice use, including:

• Inadequate processes for triggering hospice care discussions and referrals
• Oncologists’ uneasiness initiating discussions with patients about transitioning to solely comfort-focused care 
• Lack of clinicians certified in palliative or EOL care 
• Lack of culturally similar clinicians to discuss EOL care with immigrant and minority patients
• Patient and family discomfort with EOL care discussions 
• Patient populations with a reluctance (associated with cultural beliefs/attitudes) to hospice care 

The Hospice Foundation of America⁹ asserts that the most common comment heard from patients and families is a wish to have received earlier hospice care, suggesting the possibility that more OCM patients and families could benefit from earlier discussions. The foundation offers virtual continuing professional education on hospice. Other organizations, notably the Institute for Healthcare Improvement, provide resources such as The Conversation Project¹⁰ to facilitate discussions about EOL care, including hospice. Finally, shared decision-making training and tools also have the potential to support earlier hospice discussions.²

Medication Utilization and Selection: Part B and Part D Therapies and Pathways

Part B Drug Utilization

OCM assessed payments for Part B chemotherapy drugs and nonchemotherapy drugs to see what impact OCM had on the utilization and overall payments for these therapies. For Part B payments, which are about 31% of the TEPs, the OCM led to a relative reduction in the payments for the supportive care and nonchemotherapy drugs but not in the chemotherapy drugs themselves used in each cancer episode, except in high-risk breast cancer episodes. The supportive care drugs included antiemetics, blood growth factors, and bone-modifying agents; the OCM led to more value-based use of these supportive therapies.

Part B Drug Selection/Choice of Therapy

The OCM requires practices to follow national clinical guidelines and incentivizes practices to select less costly treatment options when appropriate, and to reduce low-value care. However, there were concerns that the OCM could potentially have unintended consequences of incentivizing the reduction of costly but potentially beneficial treatments. Evidence in this report shows that the OCM has had no impact on choice of drug treatment regimens, or adoption of new treatments, for any of the common cancer types examined. In fact, for certain cancers (ie, lung cancer, head and neck, bladder, liver, and melanoma), the OCM led to a relative increase in the use of new and novel therapies, such as immunotherapies, and increased access compared with their comparator practices. 

Part D Therapies

The OCM has had no impact on payments for Part D therapies overall even though the model did have a statistically significant increase in Part D payments for high-intensity prostate cancer due to the use of newer novel therapies since baseline (baseline=$19,856; PP5 $699 more in OCM than in comparison episodes [P<.05], a 3.5% increase over baseline). Also, the OCM did not improve overall oral adherence to Part D drug treatment regimens in White and Hispanic beneficiaries but did lead to modest improvements in Black beneficiaries (as their baseline adherence rates were lower than their counterparts).¹ 

Guideline and Pathway Use

The requirement of OCM practices to adhere to evidence-based guidelines has promoted the use of guidelines and pathways in both OCM and non-OCM patients. Some practices are following clinical guidelines from the National Comprehensive Cancer Network and/or the American Society of Clinical Oncology; some are using treatment pathways software programs to standardize cancer treatment regimens among all of their oncologists; others are developing or have developed their own pathways rather than purchasing vendor products. 

Further Opportunities

Many OCM practices commented that they do not want cost to influence the drugs oncologists use to treat cancer. And so, while the OCM did not affect patient access to new and often expensive therapies, this model has not led to preferential selection of less costly chemotherapy treatment approaches—a possible area for further exploration.

For Part D drugs, the adherence rates have remained above 80% in both OCM and comparison practices. OCM practices are continuing their improvement efforts by focusing on enhanced patient education and addressing barriers such as high out-of-pocket costs to reduce the impact to adherence. One OCM practice, for example, called their cancer patients before refilling prescriptions and found that 20% did not know how to safely take their medications and 30% did not know what their medications were for. The practice revamped their patient education with a required video for all patients who are prescribed oral cancer treatments. As many practices continue to leverage patient navigators, care coordinators, and/or pharmacists to educate patients about their oral drugs, assess tolerance, monitor for side effects, check that prescriptions are being taken as scheduled, and address financial or other barriers, these practices will support the further improvement of patient adherence and patient health outcomes.¹¹

Value transformation continues with evaluation of the remaining six OCM PPs still to be completed by CMS. COVID-19 has disrupted the launch of the Oncology Care First model, with the present OCM burdened by the financial strains of the pandemic, COVID-19-related staff distress, and delays and disruptions in patient cancer care. It is likely that practices will be contending with the COVID-19 threat and associated stressors for the foreseeable future, as the country grapples with new, more rapidly spreading variants, and slowing vaccination rates. The degree of threat and distress may fluctuate and vary by community, potentially impacted by factors such as a community success with vaccination, testing, and tracing rates.¹²

As of PP5, the OCM has yet to demonstrate an overarching impact on the costs of cancer care; however, there are some promising aspects notable in this report including the relative payment reduction in certain types of higher-risk episodes including lung cancer, lymphoma, colorectal cancer, and high-risk breast cancer as well as a shift in costs to less costly but effective supportive therapies. When it comes to EOL and hospice care, initiatives to address earlier referrals, palliative services, and hiring qualified staff are being put in place to help further support patient-centered care, which may lead to the reduction in EOL costs in subsequent PPs. Opportunities to meet the OCM goals remain, however, including improving depression support for cancer patients, adding capacity to address psychosocial needs, further enhancing the patient experience in Hispanic populations, and finding further efficiencies in the delivery of care to reduce costs. 

As novel therapies, especially oral oncolytics, continue to become the standard of cancer care, the costs of care will continue to increase, creating financial toxicity challenges for patients and adherence challenges for oncology care teams.¹³ Therefore, to achieve better outcomes with these therapies and improve patients’ quality of life (QOL), it will be critical to support their care through expanded use of shared decision-making, emotional support, hospice discussions, and survivorship care. Identifying and addressing disparities in cancer care resulting from social determinants of health will also be vital as COVID-19 has highlighted the adverse impact of these factors on patient outcomes and QOL.¹⁴

Innovative, population-based payment models with capitated risk assumption (adjusted by factors such as clinical risk severity), may further evolve value-based cancer care, with inclusion of value-based arrangement pilots between manufacturers and cancer care teams. The Community Oncology Alliance reports some manufacturers are prepared to participate in such arrangements, assuming regulatory support from The Center for Medicare & Medicaid Innovation.¹⁵ Expedited adoption, access, analysis, and adaptation of innovative technologies, such as telehealth¹⁶ and hospital-at-home care models,¹⁷ offer additional transformation opportunities, with some calling for “creation of a quality-based, sustainable, and patient-centric virtual cancer care model.”¹⁸ 

Success of these models will be accelerated by robust application of improvement science methodologies, such as the continuous quality improvement methodology described in the Framework for Cancer Quality Improvement,¹⁹ and value-based care transformation frameworks, such as the Value Based Cancer Care Framework summarized by City of Hope.²⁰ The framework can be found in in their recent article describing their academic and community team-based approaches to implementing multidisciplinary pathways. With national costs for cancer care²¹ projected to increase by 34% (2015-2030) due to population changes alone, payers will continue to aggressively drive value transformation models in pursuit of the Quadruple Aim.

Authors: Maureen Hennessey, PhD, CPCC, CPHQ; Elizabeth Oyekan, PharmD, FCSHP, CPHQ

Affiliations: PRECISIONvalue and Precision Value & Health

Disclosures: PRECISIONvalue, part of Precision Value & Health, performs value and access consulting services and has provided those to entities that may be involved in value-based