End of OCM Brings Drop-Off in Value-Based Care Volume, New Questions

Publication
Article
Pharmacy Practice in Focus: OncologyJune 2024
Volume 6
Issue 4

Questions arise around equity and revenue challenges.

Woman with cancer -- Image credit: Africa Studio | stock.adobe.com

Image credit: Africa Studio | stock.adobe.com

The end of the Oncology Care Model (OCM) and the financial incentives that came with it have led to significant drops in the volume of care conducted under value-based designs, according to oncology network and practice leaders who offered an update, during the Community Oncology Alliance (COA) 2024 Community Oncology Conference in Orlando, Florida. The change raises important questions about how to deliver care equitably when the revenue picture has shifted so sharply.

When asked how much the share of practice volume in value-based care had dropped since the end of the OCM, panel moderator Stephen Divers, MD, chief medical officer of the American Oncology Network and medical oncologist at Genesis Cancer and Blood Institute in Hot Springs, Arkansas, noted that the percentages varied, and panelist Barry Russo, MBA, CEO of the Center for Cancer and Blood Disorders in Fort Worth, Texas, estimated it to be 30% to 70%. The arrangements that remain are largely bonus-type arrangements, or upside risk only, according to the COA panelists. However, for practices that did not sign on for the Enhancing Oncology Model (EOM), downside risk models are harder to find.

During the OCM, practices were required to extend new services to patients, such as patient navigation and advanced care planning, which improved the patient experience and helped achieve savings. Most practices opted to extend these services to all patients because “it’s the right thing to do,” said panelist Lalan Wilfong, MD, medical oncologist at Texas Oncology and senior vice president of payer and care transformation at The US Oncology Network in Rowlett, Texas. “I wish I knew the secret sauce.”

According to Wilfong, economics have shifted from the days when drug margin compression was the main issue. Today, before you extend services to patients outside a reimbursement model, “you really have to think through that as a practice when you get into risk-bearing entities,” he said. “Your economics change quite a bit [in] how you practice medicine.”

Comparatively, few practices signed on for Medicare’s EOM because the financial package was seen as unpalatable and because the program did not allow practices a test period of upside risk only, as had been the case with the OCM. Since the launch of the EOM on July 1, 2023, CMS initiated a rule that allows practices to separately bill for patient navigation—even for practices not inside the EOM—which could make the bottom line more attractive. However, CMS would have to reopen the model for it to expand beyond the 44 practices that initially signed up.

Additionally, Russo discussed how relationships with primary care providers (PCPs) are increasingly important in cancer care, not only for referrals but also for establishing improved continuity of care that is better for patients and helps hold down costs. “That’s becoming a much larger piece of our value-based world,” Russo said.

Working With Primary Care

Many oncology practices may have formal or informal relationships with PCPs in capitated payment models with payers, Russo explained. These physicians are now keenly interested in keeping patients out of the hospital.

Divers asked whether data are keeping up with the task, and Russo said this is a concern. He said he’d met with a primary care practice that he thought would get data back within 30 days and learned that it was closer to 90 days. “The problem with that is if you want to change behavior, you can’t,” Russo said. “It’s too late.”

Like Russo’s practice, the practice of panelist S. McDonald Wade III, MD, an oncologist at the Virginia Cancer Institute in Mechanicsville, took part in the OCM but did not move forward to the EOM. In the OCM, the Virginia Cancer Institute brought services such as dietitians and care managers in-house and implemented practices that have proved valuable. “It’s so important to be able to reach out to your patients at least once a week or so to see how they’re doing, [and] to make sure you’re doing everything you can to keep them out of the hospital,” Wade said.

Both Wade and Russo have had PCPs ask questions about the level of care for patients with hard-to-treat cancers. Thus far, Wade’s relationships with PCPs are informal; he deals with physicians one-on-one and is not in any capitated relationships. In Russo’s practice, some of the relationships are more evolved; he got a call from a primary care practice wanting to know why a patient had an extended hospital stay. “He has acute leukemia,” Russo said.

Divers agreed that working with primary care has its pros and cons and that PCPs may need more education to understand what levels of care might be needed in oncology—and when it might be necessarily expensive. “Part of a risk-bearing entity here is [we] have to be a good steward of the dollar, but we [have] to keep that patient first,” Divers said. “So, what guardrails do you put in place when you start to set up these guidelines discussions?”

Wilfong said that’s something that they commonly struggle with, adding that almost every oncologist can point to an example of a patient who was treated too long and a case where a patient did not receive the level of care needed.

When discussing the right balance, the panelists addressed how artificial intelligence solutions could help, but at a cost. Both Russo and Wilfong described the number of people it takes to correctly care for patients with cancer as well as the investment it takes and how revenue streams do not always align with costs.

“It takes a village to take care of a patient [with cancer],” Russo said. “That village is not just the people in your organization—it’s a lot of people outside your organization,” which can include foundations or insurance brokers who can help fill gaps for patientswho need to get on the right coverage plan. “If they’re not in your village now, you need to start building your village because it’s essential to make this thing work for your patients in your practice.”

Reference

Divers S, Russo B, Wade SM, Wilfong L. Defining value in oncology: executing VBC accurately & ethically to account for all stakeholders. Presented at: Community Oncology Alliance 2024 Community Oncology Conference; April 4-5, 2024; Orlando, FL.
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