The COVID-19 pandemic has not only resulted in adjustments to the current Oncology Care Model (OCM), but it has led to considerations for future models, said Lara M. Strawbridge, MPH, Director, Ambulatory Payment Models, Center for Medicare and Medicaid Innovation (CMMI), Washington, DC, during the 2020 virtual National Comprehensive Cancer Network Oncology Policy Summit.
In June, the Centers for Medicare & Medicaid Services (CMS) announced several COVID-19–related flexibilities to current and future CMMI models. One of these flexibilities gives practices the option to forgo upside and downside risk for performance periods affected by the public health emergency (PHE).
“For those that choose to remain in risk, we will plan to remove all episodes that have a COVID-19 diagnosis in them from the reconciliation that determines whether a performance-based payment or recoupment will occur with that practice,” Ms Strawbridge said. “We have tried to mitigate the risks that our practices face while they are participating in the model and provide some choices,” she added.
In addition, reporting quality measures and clinical and staging data are optional during the performance periods affected by the PHE, and other reporting requirements around cost and resource utilization data have been removed, with the goal of reducing participation burden.
The OCM model has also been extended for 1 year through June 2022. “This last change, the extension of OCM, gives us much needed time to think about how COVID-19 and the experience of the public health emergency could or should inform the design of a future oncology model,” Ms Strawbridge noted.
Proposed Oncology Care First Model
Ms Strawbridge spoke in detail regarding the proposed Oncology Care First (OCF) model, which would be distinct from the current OCM. The OCF model would include a prospective, monthly capitation payment per patient for a participant’s assigned population of Medicare beneficiaries with cancer. This would include payment for evaluation and management services and drug administration services. Under the proposed model, practices would be accountable for total Medicare costs, including drug costs, incurred during a 6-month episode of care with a chemotherapy drug. They would have the opportunity to achieve a performance-based payment; there would also be a novel therapy adjustment for newly approved, more expensive drugs.
“The payment that would replace those fee-for-service bills would be a per beneficiary per month type of payment that would hopefully free oncologists to design their care approach to the needs of any given patient,” said Ms Strawbridge. “We are also considering adding electronic patient reported health outcomes to the requirements in the OCF model as a way to try to build on the practice transformation work that we have done in OCM.”
It is still not known which of the COVID-19–related flexibilities will remain permanently through CMS regulations, although expanded telehealth reimbursement is one change currently under consideration.
“To the extent that any of the flexibilities that we have right now are not made permanent over the longer term, the question remains: Should we potentially test some of them as part of a future oncology model?” she said. “For example, if telehealth flexibility is narrowed for oncologists, should we potentially give some kind of waiver to allow continued flexibility in an OCF-like model?”
It is also unclear how to ideally provide telehealth services for patients with cancer. “I am hopeful that this time in a public health emergency has been helpful to our understanding of the types of patient visits that can and should be done over telehealth versus in person,” said Ms Strawbridge.
The effect of the PHE on the duration of the shift to telehealth and other care patterns is a picture that is still evolving, and will influence future payment models, she noted.
Another uncertainty is how to tweak models, methodologies, and requirements in a future extreme or uncontrollable situation. To the extent that this PHE ends, another one may emerge in the future, which could dictate how risk is handled, Ms Strawbridge concluded.