A pair of studies evaluating the impact of the Oncology Care Model (OCM) has highlighted challenges in improving quality of the value-based payment model, according to data presented at the 2023 ASCO Quality Care Symposium. Both studies were conducted by the Centers for Medicare & Medicaid Services (CMS) OCM Evaluation Team.

The first study demonstrated the potential for cost savings in fee-for-service Medicare beneficiaries undergoing chemotherapy. However, researchers found no improvements across several quality measures related to timely and effective care vs comparison groups that did not adopt the payment model.¹ Although the second study showed improvements in practice-reported rates of screening for pain and depression, patient reported symptoms of pain and emotional problems did not improve, nor did the proportion of patients reporting receiving help with these symptoms if they had them.² Based on these findings, authors of the studies emphasized the need for further evaluation to understand and address the limitations of value-based payment structures.

Impact of OCM on Quality of Care

“Aside from a small decrease in hospitalizations in the last month of life, our study showed no differential improvement for OCM vs comparison episodes,” said lead study author Nancy Lynn Keating, MD, MPH, Professor of Health Care Policy at Harvard Medical School and Professor of Medicine and Practicing General Internist at Brigham and Women’s Hospital, Boston. “More work is needed to understand variation in quality measures, how much improvement can be expected, and whether two-sided risk models like the Enhancing Oncology Model may improve quality.”

Aside from a small decrease in hospitalizations in the last month of life, our study showed no differential improvement for OCM vs comparison episodes.

— Nancy Lynn Keating, MD, MPH

Tweet this quote

As Dr. Keating explained, the OCM was a voluntary, episode-based alternative payment model designed to improve the value of care for fee-for-service Medicare beneficiaries receiving systemic therapy for cancer. Participating practices received monthly payments to support care transformation and could earn performance-based payments (or be responsible for recoupments) dependent on meeting quality and spending goals during 6-month episodes.

For this evaluation, Dr. Keating and colleagues examined OCM impacts on care quality during 6-month episodes before (July 2014 to January 2016) and after (July 2016 to June 2021) OCM began using a difference-in-differences design. The researchers studied three of the five quality measures used to determine OCM performance-based payments in OCM—measures that could be assessed for both OCM and comparison episodes—and nine additional measures of oncology care quality endorsed by the CMS, the National Quality Forum, ASCO, or national guidelines. Statistical significance was defined as P < .10 to avoid missing program impacts.

Through the first nine performance periods, OCM led to a $499 relative savings in OCM vs comparison episodes. According to Dr. Keating, these relative savings did not include monthly enhanced oncology service payments of $160 per month, which totaled about $720 on average across the practices. In addition, she noted, savings increased between 2016 and 2021, which suggests “practices got better at saving money over time.”

Despite demonstrating relative financial savings, however, evaluation of the OCM showed minimal improvements in the quality of oncology care with respect to measured outcomes. Emergency department visits, pain intensity quantification, depression screening, and patient-reported experience of care with the OCM remained nearly identical to those of comparison episodes. Only one measure, hospitalizations in the last 30 days of life, was statistically different between cohorts, according to Dr. Keating, but its overall impact was not substantial.

“The take-home message here is there was basically no change with the OCM,” said Dr. Keating, who underscored the complexity of transforming fee-based service systems into value-based models. She says further research should focus on whether two-sided risk models, such as the Enhancing Oncology Model, offer a higher potential to improve the quality of oncology care.

The OCM’s Approach to Pain and Depression Management

Sean McClellan, PhD

A separate study of the OCM, presented by Sean McClellan, PhD, a health services researcher at Abt Associates, focused on outcomes related to managing pain and depression, frequent side effects experienced by many patients undergoing cancer treatment.

“Prior to the OCM, [depression and pain assessment and management] were areas in need of attention,” said Dr. McClellan. “The OCM, along with its in-built financial incentives, aimed to tackle these issues by promoting better screening and management methods at participating practices.”

For this evaluation, the researchers assessed changes through the first 5 years of OCM in two National Quality Forum–endorsed quality measures reported by OCM practices twice yearly: (1) Screening for Depression and Follow-up Plan; and (2) Pain Assessment and Management. The measures reflected the proportion of OCM patients who were assessed and received a follow-up plan if indicated.

Dr. McClellan and colleagues also surveyed Medicare fee-for-service patients who had OCM episodes quarterly (n = 179,445 respondents; response rate = 45%). The survey assessed whether patients experienced symptoms of pain or emotional problems, such as anxiety or depression, and whether their cancer team tried to help address those symptoms if present. For the patient survey measures, the researchers estimated risk-adjusted trends in patient responses over time, from the baseline survey through the first 5 years of OCM.

Improvements in Screening and Management Practices

As Dr. McClellan reported, oncology practices participating in OCM reported substantial improvements in screening and management practices for pain and depression in patients with cancer during the model. Practice-reported rates of depression screening and follow-up plan increased by more than 20%, from 57.2% in the second 6-month performance period to 77.9% in the ninth performance period (P < .05). Rates for pain assessment and management also improved by more than 11%, from 77.6% in the second performance period to 88.8% in the eighth performance period (P < .05).

Despite these improvements in the practices’ performance measures, however, patient-reported outcomes told a different story, with approximately 50% of patients indicating they had symptoms of depression and pain at both the beginning and the end of the model.

At the start of OCM, 49.9% of patients undergoing chemotherapy at OCM practices reported they were bothered by emotional problems, and 54.5% reported they were bothered by pain. Although nearly half of patients who reported emotional problems at baseline indicated their care team “definitely” tried to help, there was no significant change over time. Similarly, OCM patients reported little change over time in symptoms for pain or in the likelihood of getting help from their care team in managing their pain.

“Screening is an important first step for addressing pain and depression, but additional efforts may be needed to ensure screening leads to meaningful improvement in symptom management, even if it’s just communicating with patients about their options and about these issues,” said Dr. McClellan. 

DISCLOSURE: Dr. Keating and Dr. McClellan conducted this research as part of the CMS Oncology Care Model Evaluation Team under contract with the Centers for Medicare & Medicaid Services.

REFERENCES

1. Keating NL, Brooks GA, Landrum MB, et al: Has the Oncology Care Model improved quality of oncology care? 2023 ASCO Quality Care Symposium. Abstract 2. Presented October 27, 2023.

2. McClellan S, Keating NL, Brook GA, et al: Do OCM-related increases in screening for depression and pain improve patient-reported symptoms? 2023 ASCO Quality Care Symposium. Abstract 299. Presented October 27, 2023.