Community Oncology Alliance Announces ‘OCM 2.0’ Proposal, an Ambitious Reform Model to Improve Cancer Care and Reduce Costs

Author: Community Oncology Alliance

June 11, 2019

PTAC Application Demonstrates Community Oncology’s Continued Leadership in Providing Solutions to Cancer Care Cost and Quality Challenges

The Community Oncology Alliance (COA) has submitted an innovative and ambitious reform model to improve quality, reduce costs, and provide important additional cancer care services to patients, caregivers, and survivors.

Known as the “OCM 2.0”, the detailed plan is an alternative payment model (APM) that was presented by COA to the Physician-Focused Payment Model Technical Advisory Committee (PTAC), an advisory committee that evaluates physician-focused payment models for the Secretary of Health and Human Services (HHS).

It is built upon, and provides numerous enhancements to, the ongoing Center for Medicare & Medicaid Innovation (CMMI) Oncology Care Model (OCM), including a proposal for value-based cancer drug selection and pricing. If implemented, the OCM 2.0 model would streamline implementation and operations for oncology practices participating in the program, as well as address the issue of increasing costs of cancer drugs.

“This proposal reflects a commitment to helping build the cancer care system of the future that patients, providers, and payers all want,” said Michael Diaz, MD, president of COA and a practicing medical oncologist at Florida Cancer Specialists & Research Institute.  “We urgently request that the committee take the recommendations of community oncology practices who are on the frontlines of treating this devastating disease and help us transform cancer care for generations to come.”

Learning & Growing from Deep OCM Experience

The OCM is an APM that aims to provide high-quality, coordinated oncology care at the same or lower cost to Medicare. Nearly 200 oncology practices treating more than 150,000 Medicare beneficiaries signed on to the OCM when CMMI launched the program in spring 2016. Although participating oncology practices have credited the OCM with helping them to improve the way they deliver cancer care, these same practices have criticized the program’s fundamental shortcomings, including its complexities and burdensome reporting requirements.

As host to a peer-to-peer network of participating OCM practices and a leader representing independent, community-based cancer care, COA began formulating a patient-focused payment model that would improve on the OCM. In developing the OCM 2.0 model, COA has applied the lessons learned and used the feedback of participants in the OCM, as well as other APMs that have followed CMMI’s lead.

Initially targeted at the Medicare population, the OCM 2.0 model includes provisions for the universal adoption of the model in commercially insured populations. COA’s goal has been to develop a flexible and adaptable universal payment reform model for all aspects of cancer care, regardless of payer—Medicare, commercial insurance provider, or self-insured employer. In an audit conducted earlier this year, COA identified at least 20 active oncology payment models, all with different standards and metrics. It is critical that standards be developed to promote efficiency and wider adaption of meaningful reform concepts.

COA’s OCM 2.0 Highlights

  1. A flexible and adaptable universal payment reform model for all aspects of cancer care, regardless of payer.
  2. Recognizes and rewards high quality and value in cancer care.
  3. Promotes simplicity in reporting requirements and transparency in the calculations that determine reimbursement.
  4. Addresses the price of cancer drugs by incorporating value-based initiatives to facilitate the correct care for each patient, while addressing disincentives for providing suboptimal care.

In addition to incentives to ensure value in cancer drug selection and pricing, COA’s OCM 2.0 model features transparency and uniformity, an accreditation program to recognize and monitor exceptional cancer care, and a standard set of procedure and outcomes measures.

“As payment plans or initiatives have evolved, they have become more complicated and less transparent. The OCM has one of the most complex payment methodologies,” COA writes in the PTAC application’s introduction. “Since the OCM 2.0 is intended to further the OCM, emphasis is on greater simplicity, clarity, transparency, understanding, and timely reporting and communications.” COA maintains that it is important for all partners in any new payment methodology to have an understanding and agreement on all formulas and processes.

COA believes a payment system focused on recognizing and rewarding high quality and value is the prerequisite to meaningful, long-term, positive improvement in cancer care delivery. The OCM 2.0 payment methodology utilizes the standards of the Oncology Medical Home (OMH) to ensure integrated and coordinated care. The OMH rigorously mandates care that is consistent with the highest national standards while empowering the medical oncology team to determine how best to implement.

A Novel OCM 2.0 Proposal: Managing Rising Drug Costs

With the OCM 2.0 model, COA seeks to address the most significant obstacle preventing progress in value—the ever-increasing and unsustainable cost of cancer drugs and therapies. OCM 2.0 posits that the greatest opportunity for making progress in value in cancer care delivery requires a focus on managing drug choices and their costs. It incorporates value-based insurance design (VBID) principles that facilitate providing the correct care for each individual patient while sustaining disincentives for suboptimal care.

In addition, the OCM 2.0 model seeks regulatory relief to foster specific value-based initiatives in the marketplace in drug utilization. In particular, it proposes waivers for drug companies from various statutes and regulations that will open the door for positive changes in drug pricing. CMMI has the latitude to address these obstacles to allow for value-based arrangements directly with providers, the stakeholder whose primary responsibility is patient care. Appropriate waivers must be provided in advance of value-based and cost-reducing interventions between drug companies and cancer care teams. Some examples that may be considered include:

  • Guaranteed specified tumor reduction or money back to the provider and/or the patient;
  • Guaranteed reduction in the total cost of care for a specified time frame and as compared to traditional treatment for the same disease;
  • Guaranteed lowest cost per progression-free survival year.

To date, six leading pharmaceutical manufacturers have volunteered to participate in a pilot program to test more patient-centric, outcomes-related value programs provided that regulatory obstacles are in a way that would permit these controlled, limited models.

What Exactly is the PTAC?

The Physician-Focused Payment Model Technical Advisory Committee (PTAC) was established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) for the express purpose of reviewing physician-focused payment models put forth by stakeholders.

The PTAC comments and makes recommendations to the Secretary of Health and Human Services regarding whether such proposals meet established criteria. Members include both physicians and non-physicians.

The PTAC discusses its assessment of proposals in public meetings and makes recommendations to the HHS secretary, who must provide a detailed response but is not required to accept the committee’s recommendations.

The Need for Flexibility

Despite the progress and standardization in oncology payment reform that has evolved over recent years, COA recognizes the need for flexibility. The OCM 2.0 model responds to this need in two ways: the ability to adjust the model components based on payer capabilities, and secondly, the structural creation of options for health care providers to administer the requirements.

Cancer care teams by nature come in different shapes, sizes, and capabilities, and each has unique characteristics. Since engagement is critically important to all stakeholders and providers of health care, COA strongly believes any reform initiative should include flexibility for each team to determine how best to meet the basic reporting demanded within the defined and specified core requirements.

“Implementation of OCM 2.0 will require a higher degree of collaboration, communication, and transparency than what has been demonstrated in the OCM,” COA states in the application. “Cancer care is complex and in a rapid and constant state of flux due to ever-increasing improvements in biotechnology and biopharmaceutical breakthroughs. It is understood and expected that adjustments will, of necessity, keep pace accordingly and dynamically through the life of the OCM 2.0. All revisions or improvements would be accomplished through regularly scheduled meetings of a small group of appointed decision makers. These individuals will be recognized leaders of the participating provider and payer groups.”

A Call to Action: Submit Comments on the OCM 2.0

With the publication of the OCM 2.0 model proposal, a three-week comment period begins. COA encourages all who have a stake in improving cancer care and reducing its cost to submit comments supporting the OCM 2.0 to the PTAC by July 1, 2019.

For more information and instructions on how to comment, please visit https://www.communityoncology.org/wp-content/uploads/sites/20/2019/06/COA-PTAC.pdf