The updated version of the Oncology Care Model (OCM) incentivizes value-based care over volume, but some wonder if it is enough.
Bobby Green, MD, President and Chief Medical Officer at Thyme Care, Nashville, Tennessee, has been in practice for more than 25 years. Green walks pharmacists through one of the most impactful payment models in oncology today, providing a natural break down of the enhancing oncology model (EOM) and how it works for patients and health care providers in Medicare and Medicaid. Prepare for candid discussion that invites pharmacists to learn more about how EOM incentivizes value-based care, adjusts for novel therapy use, and gain a better understanding about what could be causing slower adoption rates.
PT Staff: Jumping right into it. I like the philosophy that sometimes people say understanding something means you can explain it to a five-year-old. And so as if you were explaining EOM to a group of young listeners, how would you, in layman terms, describe what it is and what it means for patients?
Bobby Green, MD: Yeah. So, I love the framing of the question, Erin. In health care, as a rule (this is not specific to oncology) we live in what's called a fee-for-service environment. And all that means is that in health care, every time a doctor (or a hospital or a radiology center) performs a service, they get paid for that service.
So, if I walk into an examination room as an oncologist, and I see a patient and I do a note on the patient, I make a decision about that patient. If that patient has Medicare, I submit a bill to the Centers for Medicaid and Medicare (CMS) [who] pays me for what I did. If I order a computerized tomography (CT) scan that's done at a hospital down the street, that CAT scan gets done, that hospital sends the bill to Medicare and Medicare pays the bill. So there are all these things that get done. And there is a charge for them. And the payer (in this case, Medicare) pays for them. And it's called fee-for-service because you get paid a fee for every service that you do.
And the only way you get paid is by doing things. The global problem with this fee-for-service model is that the more you do, the more you get paid. And so it inherently incentivizes volume. And there are only a limited number of things, things for which there are codes that you actually get paid for. But the reality is, in medical practice, there are lots of things that you could do, should do, would like to do that actually provide value to patients, but you don't get paid for them. And so the fact that you don't get paid for certain things, results in disincentivizing, those things getting done, or making them impractical.
So just to give you an example, I just mentioned the case of if a patient comes into my office, I can see the patient. And I can examine the patient and I can bill Medicare for that. And I'm going to get paid for that. And it's important to do that right. As a clinician, you need to like see patients and take care of them. And you should get paid for that. But if I've given a patient chemotherapy, and it's a week after their chemotherapy, and I know that it would be helpful if I called that patient on the phone to check on them. Not only would it be helpful, but if I asked them a bunch of symptoms that they had, I could maybe find, “Oh, they're having nausea, maybe that nausea is going to get worse in a few days and is going to put them in the hospital.”
And if I found that patient a week later and identified that they had nausea, I could do something about it, which would prevent them from ending up in the hospital 3 days or a week later. I should do that because not only is that the right thing for the patient, but ultimately, it's going to save money for Medicare because it's going to prevent a hospital admission that Medicare was going to have to pay for. And guess what? Medicare should pay me or pay the practice or pay someone to reach out to that patient a week after they get their treatment so that you can identify the symptoms and keep people from going to the hospital because that's good for the patient. And it actually saves money to do to pay me to reach out at the end of the day is going to save money, because it's going to keep that patient that's going to keep that patient out of the hospital. But the reality is, that's not how the world works.
There are a lot of things like that (reaching out a week after chemotherapy) that are not reimbursed. And it's expensive for practices to do that. It costs money. You have to hire a nurse; you have to have the nurse call the patient a week later. Operationally it's complex, like okay, I need to keep track of all the people who were starting treatment on a Monday and make sure we call them, whatever it is (3 days later or a week later), and if they don't pick up the phone I want to make sure I call them again. Or maybe there's technology I could buy that would allow me to text the patient to ask for their symptoms.”
But all these things are hard, and they cost money and no one's paying for them. And so there are all these things that don't get done.
So the key is, in a fee-for-service model, there are only specific things that get paid for that encourages volume over value. And at the same time, there are lots of other things that could be done and should be done. And in oncology practice, specifically, a lot of them do get done. But they're just a bunch of other things that don't, because no one's willing to pay for them.
And it's a shame because they could drive a lot of value. So in a value-based arrangement—this is sort of the key point—in a value-based arrangement, you change the reimbursement system one way or the other to put value on doing the things that are good for patients that aren't currently reimbursed, and that very often will reduce the total cost of care. And the example I just use here is come up with a model that will incentivize practices, incentivize clinics, incentivize hospitals, to do the things that drive higher value care, and that don't just drive volume.
PT Staff: Thank you so much for that explanation. That was lovely to hear it in context, I enjoyed how you broke that down, too. So, I very much appreciate that. And since this is the EOM and I am hearing it's going more towards value-based care, how is it addressing some of the high-cost areas that you mentioned? (ie hospital bills?) How is it incentivizing this value-based care and what does that look like in terms of finances, costs and exchanges?
Bobby Green, MD: So Erin, great question again. And at a very high level, there are really 2 financial components to the model. The first financial component is what CMS says is for every patient who is enrolled in this model. [Its] a monthly payment to do all these high-value things that fall under the umbrella of cancer navigation.
[CMS would say something like], “Okay, so we're going to pay you for every patient that you're taking care of for every month that they're in the program; we're going to send you a check.” That check in the EOM is for $70. It's called a Monthly Enhanced Oncology Services (MEOS) payment. “And we're going to pay you to cover the cost of you doing these things that are going to deliver value.”
Now, one of the asides, one of the criticisms of EOM, is that monthly payment was significantly less than in the prior version of this. And a lot of practices, I think, legitimately, will argue that the amount of dollars to that is paid by CMS doesn't cover all of the costs that oncology practices are being asked to do as part of this program. But from a financial perspective, one of the big components is, “Hey practice, we're going to give you money to allow you to perform these value-based interventions on patients.”
The second component is CMS basically saying, “You're going to have some skin in the game.”
And what that means is that if by participating in this program and doing these activities (and again, I'll just use the example reaching out to a patient after chemotherapy to assess symptoms) that should deliver higher-value care—okay, and remember, part of higher value care is not just delivering really good care and high quality care, but lowering the cost of care—then the cost to Medicare (for the patients you're managing) ought to be less than it would have been if you weren't participating in this program. Or more importantly, it should be less than other practices that have chosen not to participate in this program. CMS is saying that, “if you spend less money, we're going to share some of that money with you.”
Okay, so you're now financially incentivized to do things that are good for patients and that also can lower the total cost of care. But not only do you have skin in the game…so not only is [CMS] willing to share savings, but if you don't save money—if you cost [CMS] more money— then you're going to have to pay [CMS] some of the excess cost that you're spending, and that is what’s called (in EOM) a 2-sided risk. Meaning, you have upside as a practice, but you also have downside as a practice. And that's another contrast, Erin, with the first iteration of this, which was the oncology care model (OCM) and the in the OCM, by definition, every practice had some upside benefit (the ability to share in the savings if they lowered the cost of care) but taking downside risk was optional.
In the new model, EOM, if you participate in the program, you must take some degree of downside risk. And that's scary if you're a practice, right? =Because most oncology practices (and most practices in general, forget about the specialty) don't have a lot of experience with “How do I take risk?” And if you look at it from the perspective of an independent practice, as opposed to a hospital system—if you have a 10 doctor practice or 20 doctor practice or whatever— that means that at the end of the program, there's a chance Medicare's going to say, “Hey practice, you owe us X amount of dollars.” People are (it's not exactly happening like this) basically writing checks back to the government which no one wants to do, and that can be scary.
The key thing to remember is the program itself is voluntary. So, the practices that sign up are choosing to sign up. Once they go into the program, they know that, with every 6-month episode—because this sort of the program is in 6 months blocks— CMS is going to look at the data and they're either going to say, “Here's some money, it's breakeven, or give us some money.”
PT Staff: So are you noticing differences and what value-based oncology now looks like?
Bobby Green, MD: So I would say the biggest difference in the landscape is just that there is there's more familiarity with it. And for the practices that participated in the OCM, there's some experience. Certainly, if the EOM had looked like that in 2014 (when the OCM was rolled out), I think you would have had very, very few people would have enrolled because a lot of the practices that are enrolling in EOM now where there's mandatory 2-sided risk because they have some degree of comfort for having done the OCM. I'd like to tell you that the other thing that's different is like most cancer care is delivered under value-based arrangements right now as a consequence of the OCM—that tons of health plans have followed on—but that's actually not true.
Unfortunately, to date, the vast majority of cancer care is still delivered under this fee-for-service model. So I think that's part of the excitement around EOM is that hopefully it continues to sort of push things in the right direction. I will say, though, that there are some where there are big differences. And I don't know if you are also getting at this, and I'm happy to answer that as well. There are some big differences between the EOM now and the OCM from before.
The programs themselves do have some fundamental differences, some of which are, I don't want to say good or bad, some of which are viewed very positively by the oncology community, but obviously, some which are viewed (I think, appropriately,) with a concerning or worrisome lens as well.
PT Staff: Thank you, great explanation. So for a lot of our oncologists in smaller-scale health systems, I feel like it could be a little harder to weigh those risks because they don't have the support of a big system. How should they approach this model?
Bobby Green, MD: I think as people were considering this, Erin, you're 100% right. A lot of the reasons that both some smaller practices (and quite honestly, some bigger, more sophisticated practices) didn't participate was concern about the lower MEOS payment that I mentioned and concern about the mandatory risk without understanding that there was a clear enough path or really having had enough time to understand their own data and to be comfortable taking that risk.
The fact that there is a lot of operational and analytic resources that go into being successful there. And to your point, especially I think for smaller practices and smaller practices that hadn't done this before in the OCM, it was really difficult. I think that one of the things that we saw—this is just sort of based on my experience because I've been in the space and talking to a lot of oncologists who I interact with—that got practices comfortable with doing EOM was having the right partners and support to think about, “How are we going to tackle these operational issues? How are we going to do the analytics in the program?”
To people, the advice I would generally give to practices, even those that are now committed to going forward, is just making sure that you have the right partners in place and the right analytic support the right operational support. And depending on the practice, some of that will be skill sets that you have internally, some of that will be assist that you need from external third parties and vendors as well.
PT Staff: Thank you so much. I am wondering, how will the new model change access to novel therapies and clinical trials?
Bobby Green, MD: It's a great question. I will answer it in 2 ways. Maybe 2, maybe more. So I think one of the overarching concerns is that in a model like this, where you are incentivized to spend less money, the concern is obviously, “Well, novel therapies are expensive, is that just going to discourage oncologists from using novel therapies?”
I'll just sort of say (as a caveat as someone who again, has been practicing for 25 years) that I think the risk of that happening at baseline is quite low. Because I think that oncologists are out there taking care of patients and doing what is right for their patients at baseline. But one of the nice things about the EOM is that there is something built in to take into account not just the use of novel therapies—because when the costs are compared, they're compared to groups that are not participating in the EOM—so that's one way to sort of mitigate the risk of being a practice that [is] going to get penalized for using new drugs.
And there's also something called the novel therapy adjustment (NTA) that's built into the EOM that prevents, or rather that is actually considered.
[Let’s say someone asks], “Well, what happens if I'm a practice and I'm on the cutting edge of giving new therapies when they come out because that's the right things for my patients? I don't want to get penalized for that.”
The novel therapy adjuster is at least attempting to address that. And by the way, there are improvements that were made to that in the EOM compared to the OCM. I think at the end of the day it's sometimes hard to be confident, when a model like this is starting, about how well it is going to work, but there is something in there that to account for that. And honestly, I do not worry in the context of practices that are in the EOM, that patients are going to be not be denied access to novel therapies that are going to benefit them that that.
I have lots of things that keep me up at night but that doesn't keep me up at night because I'm not worried about that happening. As far as clinical trials go, a nice part of the EOM is that their practices are incentivized (for a couple of reasons) to enroll more patients on clinical trials. So if anything, this should be helpful for clinical trial accrual, and definitely not harmful.
PT Staff: I would just love to end by getting some of your sage advice, what would be one thing you'd want to tell oncologists who are participating in EOM? And how can they optimize being a part of the system?
Bobby Green, MD: I'm always hesitant to tell my colleagues things because one thing about the oncology community is it's a pretty close tight knit community. And I think that across the board, our practices and specifically the oncologists who are physician leaders at these practices, both the ones who've participated and who haven't participated, I think, really deeply understand the issue. I mean, listen, I think the key things are [that] this is a patient-focused intervention and it should always be a patient-focused intervention and sort of keeping the eye on that.
And then I think making sure so that you have the right partners to go through this. And because I think there's some practices can do a lot of this; some practices can only do a little of this. I don't think there's anyone out there who can do the whole thing soup to nuts without having the right partner. There are practices in various groups that have those and have access to those. And I think it's just important to leverage those as we move forward. And listen, I think there was a lot of debate about the EOM, I think there were things that a lot of practices that didn't like a lot of things and I think the participation is unfortunately lower than I think all of us would have liked. But I think there are a lot of really important influential practices that are in this in our in this to be successful at it and I think it's an exciting thing, and we'll it's going to be a big part of the of the conversation and the things that we're all talking about going forward.