The Centers for Medicare & Medicaid Services (CMS) posted its second annual evaluation report of the Oncology Care Model (OCM) in December 2018, covering first performance period and model year results. This article offers observations, based on data from the second annual report, on potential opportunities for improvement in utilization and other quality measures through continued emphases on end-of-life (EOL) care, chemotherapy side effect management, access facilitation, behavioral health/oncology care integration, and uniform adoption of quality improvement models. OCM quality measurement and improvement efforts continue to mature, and insights gained from early performance have potential applicability to the transformation of oncology and other specialty practices, as well as primary care.
Legislation under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established a novel approach to value-based reimbursement with the Quality Payment Program (QPP). Under the QPP, two pathways to payment were established: the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (Advanced APMs).1 The 2-sided OCM is an example of an Advanced APM, and the 5-year model (2016-2021) was designed to promote high-quality and high-value cancer care through a value-based reimbursement strategy incentivizing the transformation of cancer care delivery.2,3
In December 2018, CMS published The Report of the Oncology Care Model (OCM Report) summarizing results for Performance Period One and describing the efforts of OCMs to transform their practices for better value and population health.4 The OCM Report included data about 6-month episodes that began and ended during the first performance period (ie, began July 1, 2016-January 1, 2017, and ended by December 31, 2016-June 30, 2017). In many instances, data was compared with data collected from a group of non-OCM oncology practices that had been selected during the baseline period and found by the evaluators to be similar to the OCM practices along many dimensions.4
The OCM measures practices’ performance on an array of quality measures, including emergency department (ED) utilization and hospital admissions.5 The report did not address quality measure changes initiated after that period. For example, although ED and hospice utilization continue as performance measures, a related measure (hospital admission rates) is retiring beginning the fifth performance period, and measures assessing pain and depression care transition to pay for performance in the sixth performance period.5
Prevention of avoidable ED visits and hospitalizations is one of the primary emphases of the OCM. This article summarizes data from the OCM Report pertinent to utilization of emergency and inpatient services and offers some observations on factors potentially contributory to areas of favorable performance, as well as factors suggestive of potential opportunities for improvement, particularly as they impact ED and hospital use. These factors may be of interest to both OCM and non-OCM oncology practices seeking to transform their delivery of care to improve population health and offer better value for patients and payers. Non-OCM practices may be participating with other value-based reimbursement models, such as the MIPS arm of the QPP, in which their Medicare reimbursement is impacted by performance in 4 areas, including quality and cost.6
Advance Care Planning
The OCM Report noted a greater decline in all hospital utilization measures among the OCM practices, compared with non-OCM comparison groups, during this early OCM phase. Two of the declines, although noted as small, were nevertheless statistically significant: inpatient hospitalizations that included intensive care unit (ICU) stays and ED visits.4 The evaluators plan further analyses to determine the drivers of decreased ED use, but observed that “the OCM emphasis on advance care planning may be contributing to the estimated reductions in inpatient and ICU admissions for dying OCM patients, relative to the comparison group.”4 Analysis of surveys of bereaved family members of patients who died in OCM found that avoidance of hospital-based care at the EOL, earlier transition to hospice, and dying at home were more aligned with patient preferences and associated with better family-member ratings of overall care at EOL.7
Opportunities for improvement remain; the authors noted that, although OCM practices may be discussing hospice care with dying patients more, greater use of hospice care or improved timing of hospice entry is not yet evident.4 Continued focus by OCMs on advance care planning, including use of palliative care and discussion of hospice services,8 could further support appropriate utilization of ED and inpatient care, greater levels of patient and family satisfaction, and improved performance on the OCM quality measure assessing timely hospice utilization.5
Chemotherapy Side Effect Management
Concurrent medication education on oral and infusion chemotherapies and symptom management services have the potential to optimize patient care delivery via early interventions for adverse drug events, drug interactions, and medication errors.9 For example, Wong et al10 showed that an oral chemotherapy management pharmacy clinic offering patients chemotherapy management, concurrent medication education, and symptom management services could decrease the incidence of adverse drug reactions, drug interactions, and medication errors with favorable cost avoidance estimates.
Although OCM practices are working to identify and support patients at risk for chemotherapy toxicities, the OCM Report noted, there had not yet been a measurable impact on ED visits or hospitalizations for complications from chemotherapy.4 The OCM Report documented guideline-recommended use of antiemetics—including use of higher vs lower-intensity guideline-recommended antiemetic regimens—and noted that “antiemetic therapy for patients undergoing emetogenic infused chemotherapy did not change in the OCM group relative to comparisons” during the measurement period.4 Of note, clinical decision support (CDS) tools to facilitate guideline adherence were reported as being integrated with the electronic health record (EHR) by only 66.7% of the practices, with even fewer (55.7%) of the practices reporting CDS integration within their chemotherapy electronic order management systems in 2017.7
With regard to oral chemotherapies, the OCM Report stated that the proportion of episodes triggered by a Part D chemotherapy drug (ie, prescribed oral therapy) increased between baseline and intervention periods.4 However, variability existed among practices with regard to side effect communication and assistance and proactive monitoring for adverse effects and adherence.4 The evaluators intend to further monitor utilization of Part B and Part D chemotherapies and patient support for managing side effects.4
Additional interventions to prevent chemotherapy-associated ED and hospital admissions, and interventions to promote appropriate medication adherence and to prevent wastage, may yield improvements not only with hospital utilization but also with chemotherapy utilization. Implementation of the practice transformations listed in Box 1 may yield better value for OCMs in future reports.