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THE ONCOLOGY CARE MODEL 2.0 a Proposal to the Physician-Focused Payment Model Technical Advisory Committee (PTAC)

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THE ONCOLOGY CARE MODEL 2.0 a Proposal to the Physician-Focused Payment Model Technical Advisory Committee (PTAC) THE ONCOLOGY CARE MODEL 2.0 A Proposal to the Physician-Focused Payment Model Technical Advisory Committee (PTAC) Submitted by: Community Oncology Alliance (COA) 1225 New York Ave. NW, Suite 600 Washington, DC 20005 Key contact: Bo Gamble Director of Strategic Practice Initiatives Phone: (919) 394-1397 Email: [email protected] Tuesday, May 28, 2019 May 10, 2019 Physician-Focused Payment Model Technical Advisory Committee (PTAC) C/O HHS Asst. Secretary for Planning and Evaluation Office of Health Policy 200 Independence Avenue S.W. Washington, D.C. 20201 [email protected] Re: The Oncology Care Model 2.0 Dear Committee Members: On behalf of the Board of Directors of the Community Oncology Alliance (COA), we are pleased to submit this proposal to the Physician-Focused Payment Model Technical Advisory Committee (PTAC). COA is a national, non-profit organization that is dedicated to advocating for the complex care and access needs of patients with cancer and the community oncology practices that serve them, especially vulnerable seniors with cancer. COA is the only organization in the United States dedicated solely to independent community oncology practices, which serve the majority of Americans receiving cancer treatment. COA’s mission is to ensure that patients with cancer receive the highest quality, affordable, and accessible cancer care in their own communities, close to where they live and work. For more than 16 years, COA has built a national grassroots network of community oncology practices to advocate for public policies to support their patients with cancer. COA and community oncology as a whole are committed to meaningful, patient-centered oncology payment reform. We have been on the forefront of national efforts to advance this, including leading a collaborative network of over 80% of the participants in the Oncology Care Model (“OCM”), which provides a forum to share best practices and ideas. COA routinely communicates with the CMS Innovation Center’s OCM team on suggestions designed to address problems and concerns with the OCM. While we are committed to making the OCM a success, we have dedicated significant time and resources to developing this proposal which we are calling the “OCM 2.0” – an evolved version of the OCM 1.0 that, among other improvements, streamlines the model and incorporates value-based drug performance directly into the model. We see this as not just a Medicare model, as with the OCM 1.0, but a universal model of oncology payment. We look forward to continuing to engage with you on this innovative model. As you consider this proposal, please feel free to contact Bo Gamble, COA’s director of strategic practice initiatives at [email protected]. Sincerely, Michael Diaz, MD President, Community Oncology Alliance THE ONCOLOGY CARE MODEL 2.0 A Proposal to the Physician-Focused Payment Model Technical Advisory Committee (PTAC) Presented by the Community Oncology Alliance Table of Contents Abstract ...............................................................................................................................v Model Description ..............................................................................................................1 Criteria 1. Criterion: Scope of PFPM ........................................................................................3 2. Criterion: Quality and Cost ......................................................................................5 3. Criterion: Payment Methodology ............................................................................6 4. Criterion: Value Over Volume...............................................................................16 5. Criterion: Flexibility ..............................................................................................17 6. Criterion: Ability to be Evaluated ..........................................................................19 7. Criterion: Integration and Care Coordination ........................................................21 8. Criterion: Patient Choice........................................................................................22 9. Criterion: Patient Safety .........................................................................................24 10. Criterion: Health Information Technology ............................................................25 References & Citations ....................................................................................................26 Appendix ........................................................................................................................ A-1 Cost increases are concentrated in Part D (and Part B chemo) ................................. A-2 Table 1. OCM Compared with OCM 2.0 ................................................................. A-3 OMH Standards ...................................................................................................... A-11 Cost Differences Associated with Oncology Care Delivered in a Community Setting Versus a Hospital Setting: A Matched-Claims Analysis of Patients with Breast, Colorectal, and Lung Cancers ................................................................................. A-23 2018 Community Oncology Practice Impact Report .............................................. A-34 Top 5 Low-Value Services for Purchaser Action ................................................... A-38 Choosing Wisely: Five Things Physicians and Patients Should Question ............. A-39 OCM Performance-Based Payment Methodology ................................................. A-43 The Value and Cost of Immunotherapy Cancer Treatments ................................ A-120 Evaluation of the Oncology Care Model .............................................................. A-127 PTAC Application Letter of Intent Community Oncology Alliance Comprehensive Cancer Care Delivery Model ................................................................................ A-229 Letters of Support ……………………………………………………………….A-231 PTAC Application Submission Checklist ............................................................. A-236 Abstract The “Oncology Care Model (OCM) 2.0” is a payment reform model developed by the Community Oncology Alliance (COA), a champion for universal reform, and a recognized advocate for community oncology and access to quality, local, affordable cancer care for all patients. Cancer patients are the motivation and focus in all of COA's efforts. This application identifies the components in current reform models that are working well, areas where improvements are needed, and areas that have yet to be addressed. COA emphasizes the areas that need improvement and will lead to standardization and expansion of reform initiatives. The following stakeholders were consulted in the development of this document; active participants in the Center for Medicare & Medicaid Innovation (CMMI) OCM, other oncology reform models, and/or international value-based healthcare delivery models. Purpose: The purpose of the OCM 2.0 is to apply the lessons learned and feedback from participants from CMMI OCM model and other initiatives. COA has identified 20 active payment reform models in the United States. All have a vested interest in improving quality in cancer care and lowering costs. All of these models are different. There are some similarities related to outcomes measures, but each model is unique. This application describes the path to continued improvement of these attempts while also standardizing the base requirements of care and value- based systems. Standardization of the following concepts in the OCM 2.0 model will increase understanding and manageability to the benefit of the cancer patient and their family. Foundation: This application addresses many obstacles that are limiting the progress of implementing value-based programs. The majority of these hurdles are due to program design.to timeliness delays and misaligned incentives. This model addresses drugs, or treatments, and the costs of these drugs and treatments in the total cost of care. COA's involvement in other reform models have clarified the principles that will assist with standardization and universal acceptance: Collaboration Communications Timeliness Transparency Incentives Measurements How: This model includes two main themes: 1) standardized clinical improvements and 2) baseline payment methodology criteria. The commonality are measures that provide evidence of outstanding quality and value. These measures are then used to regulate or substantiate financial incentives within the payment methodology. COA has partnered with the American Society of Clinical Oncology (ASCO) to update the Oncology Medical Home program while including automation, or efficiency, to extract the measures that will be used for benchmarking performance in payment models. These measures will be used as the base for a collaborative payment model. The OCM 2.0 initiative is unique and directly addresses the value and price of drugs. COA researched the complexities and complications surrounding value-based arrangements with pharmaceutical manufacturers and the industry. Some of the findings were alarming, some were unexplainable, and others begged for simple solutions. COA's goal is to promote value-based arrangements that also include care teams by addressing regulatory roadblocks. v Model Description This physician-focused payment model (PFPM) is submitted by the Community Oncology Alliance (COA). It is titled "OCM 2.0"
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