ASCO Updates Its Patient-Centered Oncology Payment Model

Roxanne Nelson, RN, BSN

November 26, 2019

The American Society of Clinical of Oncology (ASCO) has released a major update to its Patient-Centered Oncology Payment (PCOP) model, an alternative payment model designed to enable all oncology practices to deliver higher-quality care at lower cost.

The update comes more than 5 years after ASCO released its first model and reflects input from medical oncologists in diverse practice settings, as well as practice administrators, payer representatives, and experts in physician payment and business analysis.

"As oncologists, we have a responsibility to shape the future of America's cancer care system," said ASCO President Howard A. "Skip" Burris III, MD, FACP, FASCO, in a statement.

"We're stewards of our patients' well-being, and ASCO's model reflects everything we have learned in over fifty years of work to advance patient care," he said. "It is a complete solution for transforming cancer care delivery and reimbursement and puts the needs of patients front and center."

The new Community-based Oncology Medical Home model is designed to be a "complete solution for transforming cancer care delivery and reimbursement while ensuring that all individuals with cancer have access to high-quality, high-value cancer care," said ASCO.

The model has three major goals: to improve the delivery and coordination of care using the oncology medical home model; to develop a reimbursement system that incentivizes quality of care through patient-centered, bundled payments; and to reduce variations in both care and cost through adherence to oncology clinical pathways that are consistent with ASCO criteria.

The first model, Consolidated Payments for Oncology Care, was released in 2014. Although it was billed as a Medicare reform, ASCO said that it would work for private insurers as well.

Expanding on that, in 2015, ASCO released details of its proposed PCOP: Payment Reform to Support Higher Quality, More Affordable Cancer Care. This model was designed to enable all oncology practices to deliver higher-quality care at lower cost. Under PCOP, oncology practices would receive a significant increase in payments for patient services in comparison with what they were currently receiving, but overall spending on cancer care would be reduced because the plan would help avoid unnecessary care.

The key changes in that 2015 PCOP proposal from the previous year's model were aimed at improving payment for oncology practices by allowing higher and more flexible payment to support patient care.

The latest update ― the new 2019 draft version ― reflects "lessons learned" from previous demonstration programs, including a PCOP pilot that was implemented in New Mexico.

So what has changed in the new update?

Jeffery Ward, MD, past chair of ASCO's Government Relations Committee and a contributor to PCOP, told Medscape Medical News that the 2015 model was built upon the concepts from the earlier proposal, which focused on high-quality care in four areas.

"We wanted to focus on emergency room and hospital admissions, adhere to evidence-based criteria, have more patient-directed end-of-life care, and more quality performance measures," said Ward, who is also an oncologist at Swedish Cancer Institute in Edmonds, Washington.

However, payers expressed concern that there weren't enough stipulations in the 2015 model. "To be quite honest, in 2015, we wanted to allow for flexibility, which we thought would allow practices to innovate and customize solutions by having that flexibility." Ward explained. "But insurers and employers felt that there should be more dictated or promised practice transformation."

Thus, the 2019 update acknowledges that payers lack trust; the updated oncology home model is much more specific than the 2015 version. "It has requirements that practices have to follow in the way they deliver care, and this satisfies the concerns of payers," said Ward.

The second important change is that clinical pathways have become a cornerstone in this update. "We built upon several years of increasing understanding and sophistication of clinical pathways, which were still a fairly nebulous idea in 2104," he said. The updated model "will still allow for flexibility, allowing a community board that involves the providers, the payers, and potentially patients to help develop the quality metrics that will be used."

One unique aspect of the proposal is that it will implement PCOP in geographic communities, with all relevant providers and payers participating. Geographic communities may be as small as a single metropolitan area or as large as several states. Depending on the size of the provider and/or payer, they could conceivably span multiple PCOP communities.

"One of the problems we have now is that contracts are payer specific," said Ward. "If you are a doctor and you have a different contract for every patient, it causes chaos, and there are tremendous issues in billing, as well as clinically — such as what metrics you are measuring and what pathway you are following."

Lessons Learned

There were also lessons learned from the Oncology Care Model (OCM) that is being piloted by the Centers for Medicare & Medicaid (CMS) Innovation, in which bundled payments include the cost of drugs. The inclusion of drug prices in a bundled payment can create substantial variation in the revenues that practices collect, and the OCM has been criticized for penalizing practices that care for patients with complex problems.

"We think that providers should be responsible for utilization of drugs, but we do not control the cost and should not be responsible for the activities of the pharmaceutical industry," said Ward. "OCM does not acknowledge that, and the result is that what they predict a cost will be and what the actual cost is can vary widely ― and this results in a huge inability to assign a bundled cost that includes drugs."

He pointed out that there can be a difference of nearly $20,000 between the actual cost and the predicted cost in an OCM bundle. "It creates a circumstance where success is not based on the skill set of a physician and making value-based decisions but is dependent who walks in the door ― do you get a favorable or unfavorable panel of patients," said Ward. "OCM purports to solve that through their winsorization, but all that does is mitigate your extent of the risk, and whether you're a winner or loser is still based on luck and not on the decisions you make."

The ASCO plan is different. Rather than being responsible for cost, a physician is responsible for utilization and pathway compliance. "I'm being rewarded for giving the right drug to the right patient at the right time and not for limiting care to my patient," he said.

Using data from the Maine Health Data Organization, ASCO has projected that PCOP could yield savings of up to 8% across the healthcare system. ASCO also plans to include PCOP as part of its response to CMS' recent request for information about next steps after the OCM is completed in 2021.

Multiple Models Needed

Approached for an independent comment, Gabrielle Betty Rocque, MD, assistant professor of medicine in the Divisions of Hematology and Oncology and Gerontology, Geriatrics, and Palliative Care at the University of Alabama at Birmingham, believes that this is a viable model.

"The model has many similarities to OCM," she said. "They have built in practice transformation components that are likely to result in high-value care, including pathways and treatment planning. I do believe that there are centers moving forward presently with the model, although I do not have the details."

Rocque added that she also believes that multiple models need to be tested, not just OCM or Oncology Care First, which is another model that has been proposed by CMS. "The ASCO approach provides a similar but distinct approach to payment reform that I believe should move forward," she said.

Ward has received honoraria from AZOncology and serves in a consulting or advisory role with New Century Health. Rocque has disclosed relationships with Genentech/Roche, Pfizer, Carevive Systems, Medscape, and Pack Health.

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