Practices Ask for Downside Risk Delay for Oncology Care Model

June 03, 2019 - An association of community oncology practices recently urged CMS to delay the October 2019 deadline for practices in the Oncology Care Model (OCM) to assume downside financial risk.

In a letter to Adam Boehler, director of the CMS Innovation Center (CMMI), the Community Oncology Alliance (COA) specifically asked CMS to postpone the deadline for the bundled payments model to April 2019 in order to give practices a third set of reconciliation data, as well as results from the period in which CMS updated bundled payment model’s risk adjusters for breast, prostate, and bladder cancer.

“Making the decision on whether to accept downside risk based on only two sets of reconciliation results/data after these key corrections to the methodology were made exposes practices to significant uncertainty rather than quantifiable risk,” the association in the letter. “This potentially threatens their viability and in turn, access to care for Medicare beneficiaries. The additional results and time to decide whether or not they will take on downside risk will enable participants to gain critical insight into their performance and move to risk in a more viable pathway.”

Recent reforms from CMS have been focused on increasing the adoption of downside financial risk among providers in Medicare alternative payment models, and the OCM is no exception.

The federal agency intends to make oncologists participating in the bundled payments model to become more accountable for the outcomes and total costs of care of patients undergoing chemotherapy episodes. Therefore, leaders required practices in the voluntary five-year model to assume downside financial risk by October 2019 if they had not already earned shared savings payments.

But providers are generally risk-averse, and oncology practices are slated to lose if they assume downside financial risk under OCM. Healthcare consulting firm Avalere recently found that 70 percent of practices in the model would have to repay CMS if they transition to the downside risk track.

Community oncology practices, the setting where the majority of cancer patients treated, need more time to evaluate OCM updates and risk methodology, and the bundled payments model could use several improvements for practice success, COA explained in the letter.

The association particularly called for changes to how CMMI determines prices.

“Applying price adjustments at the level of the practice, rather than the episode, leads to underpricing for practices that deviate from average national distributions; e.g., of population-level characteristics or cancer types,” the letter stated.

Underpricing is a significant issue for the OCM, another recent Avalere analysis found. The consulting firm’s examination of claims and prescription drug event data showed that OCM practices treated patients with Medicare costs per episode two to three percent higher than OCM prediction model estimates during the first two performance periods.

“If the OCM’s prediction model underestimates actual costs, then success for practice participants becomes more difficult,” Lance Grady, managing director at Avalere, explained in the analysis.

The COA also advised CMMI to improve pricing for outlier patients.

“CMMI should improve pricing for outlier patients so that practices are not penalized, or significantly over-target, due to a few outlier episodes. Episode-level pricing of novel therapies and chronic conditions would help improve episode pricing for practices who cannot absorb the risk of having excessively expensive episodes, especially for patients with low-risk cancers,” the association wrote.

To improve OCM price predictions, the association also recommended that CMMI account for Part D agents and adjust for emergent therapies at the episode level. The agency should also apply the novel therapy adjustment to atezolizumab.

In addition to price prediction challenges, COA also identified issues with OCM risk adjustment, patient attribution, and timeliness of data reports. The association advised CMMI to:

• Implement more sophisticated pricing models that allow for risk adjustment for high-risk patients and are more clinically motivated
• Add surgeries related to all cancer types to the surgery list so if patients undergo surgery for any type of cancer, the target price will reflect the increased complexity of their episode
• Exclude patients with certain disorders (e.g., hemophilia and Guillain-Barre syndrome) and high-utilization events from the OCM to prevent outliers beyond the oncologists control
• Notify providers as quickly possible after an episode is triggered or attribute patients to an oncologist based on the triggering chemotherapy claim
• Release monthly, rather than quarterly reports, to help practices’ manage patient costs
• Assign patients with the most resource-intensive cancer type using data from claims and staging
• Account for metastatic disease in pricing estimations