Rani Khetarpal explores what the OCM model looks like at one oncology practice in Illinois and how the program can improve to help more organizations improve care delivery and generate savings.
David Schafer: Welcome to the Specialty Care ValueCast where we explore the evolving landscape of specialty care management through the lens of value-based care, insurance risk, and the patient and provider experience. I'm David Schafer and this is the second episode in our series focused on the Oncology Care Model. In this episode we're going to look at what the oncology care model looks like day to day at one oncology practice and what challenges and opportunities they're anticipating in the program moving forward. In our last podcast, we spoke with Ed Bassin of New Century about the CMS Innovation Center's Oncology Care Model (OCM) intended to improve care and lower costs for cancer patients and the Medicare program.
Today I have another two guests with me, Stephanie Jackson of Cancer Care Specialists of Illinois or CCSI. Stephanie is a registered nurse and leads CCSI's participation in CMMI's Oncology Care Model. Also joining me is Rani Khetarpal, a Vice President and leads Oncology Care Model partnerships at New Century Health, which is working as a risk share partner with CCSI as it implements OCM. Now, Stephanie, let's start with you. What was it about OCM that first piqued the interest of CCSI? Why did you ultimately decide to participate in the program?
Stephanie Jackson: Hi, thank you for that introduction. What piqued the interest of CCSI is the ability to impact care in a positive way and ensure that we are providing high quality at a lower cost. Knowing how much money is spent on oncology through Medicare, it's essentially our responsibility as providers to ensure that we're handling those dollars most appropriately and elevating the care of our patients.
David Schafer: Thank you, Stephanie. Now I think it'd be helpful to walk us through what a day in the life within OCM looks like for CCSI. For instance, a patient is diagnosed with a certain type of cancer and of course the chemotherapy begins. How has care changed for the patient under the OCM model?
Stephanie Jackson: That's a great question. For our OCM patients, they will first be seen by the oncologist. A new addition to the team since the implementation of the Oncology Care Model is the nurse navigators. So when this patient is diagnosed and then starts treatment, they receive education through the nurse navigation program regarding their diagnosis and their treatment, including side-effects or any possible issues that may come come along the way. Then additionally, we now do some increased screening such as depression and distress, which we did before but maybe not as as consistently. So we're able to ensure that we're taking care of the entire patient and making referrals to appropriate services and finding financial assistance as needed.
David Schafer: Great. Thank you. Could you also talk a little bit about what CCSI's responsibilities are to CMS under this program and how is the payment different under OCM?
Stephanie Jackson: Our responsibilities in regards to reporting to CMS is first identifying who we feel are the qualifying patients for the model. So to qualify, patients have to be Medicare A and B or Medicare Railroad. In our area we also have a qualifier of Medicare Wabash. They have to have a cancer diagnosis and they have to be receiving treatment for that diagnosis. So once that is identified by our team, we notify Medicare by billing what's called a MEOS charge. So Medicare will give us a fee each month for delivering a higher quality and more coordinated care for that patient. Additionally, we have performance qualifiers and standards that we have to meet and so every six months we have to report on how we did in each of those areas. Additionally, we report staging metrics to the OCM registry.
Additionally, as far as all of those responsibilities to reporting to CMS go, we also ensure that each patient receives what we call a treatment plan of care at the start of treatment, which outlines everything that they've had done up until that point, provides a timeline, additional background and side-effects that they may experience as well as contact information for all of their care team. And this document is then also updated at the end of their treatment course. This is also referred to as the 13 point IOM care plan in the CMS model.
David Schafer: Thank you, Stephanie. I think that was a very helpful overview. And just to reiterate for our listeners, the MEOS payment Stephanie referred to is the Monthly Enhanced Oncology Services payment, which is $160 care coordination per member per month payment that lasts for each month of the six-month episode. Now Rani, I'd love to turn to you.
Rani Khetarpal: Sure, thank you David, and thanks for having me on today. So New Century Health really works with the intersection of payers and providers. So New Century Health, in terms of oncology, has over 17 years of experience within the oncology space providing value through the use of our outcomes-based clinical pathways and taking risk on behalf of payers. So moving into the Oncology Care Model when the two-sided risk model is coming to fruition actually is a very nice alignment where New Century Health has a lot of strengths and a lot of success in.
David Schafer: You mentioned New Century's charged with serving as a risk share partner to the people with whom we align in the market. And I was just wondering if you could provide to our listeners just a high level overview of what it means to serve as a risk share partner.
Rani Khetarpal: Sure. And it's a good question because risk in oncology is a fairly new concept and one that tends to need a little bit more explaining and certainly a risk share partner is a very new concept for the majority of folks within the oncology space. So when New Century Health looked at developing a risk based partnership model for the Oncology Care Model, we looked at really three different things. The first is that from a true partnership perspective, we have to be able to provide more than just what our core strength is around our clinical pathways. So essentially there should be a toolbox in place where we could provide support and services and platforms and programs and so forth that would support performance initiatives on behalf of the oncology clinics that that we're working with.
The second bucket is really putting our money where our mouth is. And that's really what a true risk share partner is—is that we shouldn't have an upfront fee, right? All of our fees are done on the back end, only if we succeed with our risk share partner, in this case being the oncology clinic. So if they succeed, we succeed. And so that's how we base our fee.
There's also then this downside risk, right? And again, a true risk share partner is, like I said, putting their money where their mouth is. So if they do end up losing in the two sided risk model, we're so sure that our partnership will actually help them succeed, that we're actually going to take a percentage of the downside if in fact it comes to that. So really those three buckets are what comprises a true risk share partner in this model.
David Schafer: Great. And going off of those partnerships, I think it'd be helpful to hear what types of partnerships New Century Health envisions and what a successful partnership looks like to you from your perspective.
Rani Khetarpal: So for now, given how new the risk share idea is within this space, we've started working with CCSI on what they call the "upside only" which means that there is no downside currently. So what can we do to impact their performances to bring them up to what success looks like ultimately in this model? It's not really the true measure of success but it really is ultimately what it looks like within this model, is can they achieve a performance-based payment? Will their trend line continue to go up in accordance with what they're expected to do? And that's really what we're looking at in terms of success within the one-sided model or the upside only model.
As we move into the two-sided model, of course, we definitely don't want to go below that baseline. We want them to have an upward trend. We want them to achieve a PBP. Obviously if they win, we win. That really is a measure of success. But I think it also comes down to the quality of cancer care that's being delivered. We can't discount that. So everything that we do should be enhancing that quality for that individual patient and the way that cancer care is delivered to them. If we're achieving that, then obviously that's successful as well. But when it comes in respect to the model, we certainly want to have the positive financial impact as well. So I think, suffice it to say that's really the success and the definition of it. So it's a kind of a two-pronged approach. In terms of how this will move in the future it really depends on the type of value-based care models that are going to be implemented.
As we move into 2.0, we don't know what that's going to look like right now, but we do know that there will be an element of two sided risk and we definitely want to ensure that NCH is positioned to continue to support practices that choose to participate in that model and other models that may be put forth by our commercial payers and our [Medicare] Advantage plans. So I think time will tell how this really develops, but I think we have a really good game plan moving forward as to how we're going to participate with our practices.
David Schafer: Wonderful to hear. And Stephanie, it'd be great if you could talk a little bit about the challenges that CCSI faces in the program. Pretend I'm Seema Verma and you're speaking to the areas where CMS may want to make some changes to ensure the program's future success.
Stephanie Jackson: So I definitely want to talk about some of our challenges, but I think in order to do that I have to talk about some of the strengths and growth that we found from this program. With the implementation of the OCM, we have better 24-hour access for our patients. Our patients have more coordinated care. We have implemented the treatment pathways with the help of New Century Health and we have chosen more treatments that are better in efficacy, better in tolerability to the patient, while continuing to cut cost to some degree. We have overall costs to the patient. However, with that being said, as far as challenges, we have yet to see a performance-based payment in this model. You know, although we have saved as as much as we have. So being able to correlate what we are doing operationally and in our day to day with our results in the model would be very beneficial.
As of now, there's so much complexity to this model and so many different modifiers that it's hard to say that, "We did this and we did well because of it." Or, "We did this area right here that we need to focus on." There's very little ability to link those things together at this point in time. So more transparency, I think would be, would definitely go a long way. We're looking at, being compared to our peers, some of the issues that we find is we don't know who our peers are. Who are we being compared to? It'd be nice to actually know that. We don't know our we being compared to our peers in our state? Are we being compared to peers that are of similar size and demographic?
Those are all questions. And in order to know that you're actually doing better compared to your peers you have to know that you're not comparing apples to oranges. And in many cases right now that's how it feels. Even when you're looking at comparing yourself to yourself from performance period to performance period, with the pricing model change, it's really hard to tell where you stood before versus where you stood now and trying to find those linkages.
David Schafer: So Stephanie and Rani, there's a common narrative that it's very hard to achieve success in this model because it's very difficult — almost impossible — to drive down drug spending. I think it'd be helpful to our listeners to hear you two talk about that, whether you think that narrative is true, whether there are results or evidence to maybe suggest that's actually not the case and that drug spending can be improved and reduced.
Rani Khetarpal: So that's a really great question and I think a very important one to address. And yes, I mean ever since this model was introduced, I think there was a common concern about including drug costs in the episode costs. And there still is. And really, like you mentioned, the common thought process is that we can't really affect drug cost, so we've got to focus on other areas. Well you should be focusing on other areas anyway.
But we have data to show that we can actually bring down drug cost within this model and it's not a one-sided effort. It does take effort on the part of the practice, and I'm sure Stephanie can talk through that a little bit. But the end result is for CCSI, NCH's data over the last 12 months have shown a 13.5% reduction in drug spend and which actually equates to about $250,000 per physician over the course of that 12 months. Which is quite significant when there's 14 medical oncologists in the practice. So when you add up the numbers, it's actually a quite significant savings. So the question is: how did that happen? And what was the physician thought process as they kind of tackled this issue? So I think Stephanie would probably be the best person to answer that.
Stephanie Jackson: So with the help of the pathways of what we would do is look at being first of all, on pathway in regards to NCCN guidelines. That's where the foundation for the pathways stems from. But additionally, the physicians have what we call the two-click tool from New Century Health that they get to a disease site and then which pathway is going to fit their patient best. With the implementation of that of course you're not going to get everybody on board 100% of the time, but we have a common goal to set — we're trying to shoot for 80%. Most recently we've reached 81% by January of this year.
And so we reached that goal and, in doing that, for the cases that are not on pathway, we have an every two-week meeting with New Century's Health team to review those cases that were not on pathway to determine, should it be on pathway? What was the reasoning for deviating from the pathway? And what can we learn from that, whether it be on our side or on the New Century Health side? And how can we bring all of our mindsets together towards one common goal? So that's been a huge benefit. There's no way that we cut drug spend without that relationship.
Rani Khetarpal: If I could just add one more thing, I think too what really contributed to that is the data that they receive is immediate and it's daily. So you know at any given time what your prescribing habits are that are driving up the drug costs. And you have accountability, right? I think that's the word, is that every physician is accountable to their contribution to that episode cost for the patient and for the practice. So to Stephanie's point, it takes a lot of work on the part of the practice and it takes a really committed partner to work together to help drive that cost down. And so it does take a lot of effort and you've got got to be willing and open to do that.
David Schafer: Thank you both for that comprehensive answer. I think it's nice to know that drug spending can be reduced and positively addressed in the OCM model and oncology in general. Following up, Stephanie, from some of the challenges you described as being a participant in the OCM program, I think it'd be interesting to hear about how you and your CCSI colleagues feel about transitioning to the two sided risk model in OCM. Do you feel ready? Are you still assessing whether or not that's something you want to do?
Stephanie Jackson: You know, I think that there's probably a couple of answers to that question and I think the most general answer is that we're still assessing the situation. It's really hard to go to two sided risk without more data. We're in the sixth performance period and we only have data on three performance periods, and there was a pricing model change in there. So it's really hard to determine how we're going to fare moving forward. Although I can say that there's some eagerness to try to step to two-sided and see how we do, but it's a hard decision to make without seeing some more numbers.
David Schafer: That makes sense. Thank you. And thank you both Stephanie and Rani for being our guest today. On the next podcast, we'll dive a bit deeper into some of the challenges of OCM and we'll also look at ways that can be improved to ensure oncology practices and CMS can succeed in their goals to improve cancer care and reduce costs in Medicare and across participating private payers.
The Specialty Care ValueCast is produced by New Century Health, a specialty care management company focused on oncology and cardiology, with nearly two decades of experience, improving health outcomes and reducing costs for provider and payer organizations.