The Lynx Group

Changes to the Oncology Care Model Spurred by the COVID-19 Pandemic

December 2020, Vol 11, No 6

The COVID-19 pandemic has spurred adjustments to the current Oncology Care Model (OCM) and is also affecting considerations for future models, according to Lara Strawbridge, MPH, Director, Division of Ambulatory Payment Models, Center for Medicare and Medicaid Innovation, who delivered the keynote address at the 2020 NCCN Oncology Policy Summit.

Several key reimbursement flexibilities to the OCM were announced in June 2020 in response to the public health emergency caused by the pandemic. One such flexibility is the option to forgo upside and downside reimbursement risks related to the performance periods that are affected by the public health emergency.

“For those that choose to remain in risk, we’ll 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’ve tried to mitigate the risks that our practices face, while they are participating in the model and provide some choices.”

Key changes to reporting requirements have the goal of reducing participation burden. Reporting quality measures and clinical and staging data are optional during the performance periods affected by this public health emergency. Other reporting requirements related to cost and resource utilization data have been removed.

One important change is an extension of the OCM. Originally, the OCM was a 5-year model with 9 performance periods. Now, an additional year (2 performance periods) has been added to the model, extending the OCM to mid-2022, rather than having it terminate in the summer of 2021 as originally planned.

“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 said.

She went on to discuss the future OCM, describing a few key characteristics of the potential Oncology Care First (OCF) model.

The payment methodology of the potential future model would combine 3 main components, she explained. One component is similar to the OCM accountability for total cost of care, but with relative improvements. In addition to removing low-risk episodes from the total cost of care, novel therapy adjustments would be more cancer-specific. A professional capitation approach, designed to be revenue-neutral, would replace fee-for-service billing for common services furnished by an oncologist, such as evaluation and management visits and drug administration. In this way, care choices would have no impact on the practice cash flow.

“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,” she said. “We’re 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’ve done in OCM.”

Among the pandemic-related OCM flexibilities, it is uncertain which ones will become permanent through regulations from the Centers for Medicare & Medicaid Services, specifically in oncology, she added. Expanded telehealth reimbursement is one important change under consideration.

“To the extent that any of the flexibilities that we have right now aren’t made permanent over the longer term, the question remains: should we potentially test some of them as part of a future oncology model?” Ms Strawbridge asked. “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?”

One unknown is how telehealth is ideally provided in oncology practices. “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,” Ms Strawbridge commented.

How long telehealth will continue to have an important role in cancer care because of the public health emergency is an issue that’s still evolving, and will influence future payment models, she added.

Another uncertainty is how to tweak models, methodologies, and requirements in a future public emergency. When the current public health emergency ends, another one may emerge in the future and may dictate how risk is handled, Ms Strawbridge concluded.

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