PTAC OKs New Payment Model for Community Oncology

WASHINGTON — An oncology care model that proposes to decrease overall Medicare spending, while bettering quality of care, won the approval of a Department of Health and Human Services (HHS) advisory committee.

The Physician-focused Payment Model Technical Advisory Committee (PTAC) voted Monday (7-0; one abstention) to recommend implementation of the Making Accountable Sustainable Oncology Networks (MASON) model, submitted by Innovative Oncology Business Solutions (IOBS) of Albuquerque. The company’s chief executive is Barbara McAneny, MD, who is also currently president of the American Medical Association.

PTAC was established by Congress to recommend new physician payment models in government programs.

According to IOBS, MASON “guides community-based oncologists in providing evidence-based care while receiving appropriate payments and incentives to reward quality of care and costs savings.”

MASON is adopted from the Community Oncology Medical Home (COME HOME) model that aims to have cancer care administered across clinic and hospital settings. COME HOME was developed as part of a Center for Medicare and Medicaid Innovation (CMMI) grant.

Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, and Kavita Patel MD, MPH, a primary care internist at Johns Hopkins Medicine in Baltimore, recused themselves from the vote. Both Miller and Patel stated in their disclosures that they have worked with IOBS on oncology payment in some form.

Miller attended the meeting and abstained from the vote; Patel, along with Rhonda Medows, MD, executive vice president of Population Health for Providence Health & Services, did not attend Monday.

PTAC Chair Jeffrey Bailet, MD, executive vice president for Health Care Quality and Affordability at Blue Shield of California, also disclosed that he had worked with IOBS at various meetings and congressional briefings, but said he did not feel his interactions constituted a conflict of interest.

How MASON Works

At Monday’s meeting, McAneny said physicians and health economists from the American Society of Clinical Oncology created what she believes is a more accurate payment system for reimbursing medical home costs.

“We’ve noticed for a long time that there’s certain clusters of patients who cost more than other patients with the same clinical criteria, so clearly we’re missing some of those criteria,” McAneny told MedPage Today after the meeting. “What we’re attempting to do is look for those naturally occurring clusters of cost, and then look at what are the clinical criteria that come from the practice’s electronic health records that caused those differences.”

Based on their analysis, McAneny said it is possible to more accurately determine target prices, which will prevent oncologists from being penalized if they end up with more patients in an expensive cluster than a less costly one because, in the past, patients costs were simply averaged.

In MASON, during any participating oncologist’s first meeting with a patient, that patient is assigned to a treatment plan, based on their clinical characteristics and patient preferences, and to an Oncology Payment Category (OPC) based on disease state, comorbidities, and treatment plan.

A target price is set based on the anticipated cost of cancer care in that OPC, which includes evaluation and management, infusion center facility fees, variable radiation, hospital charges, and lab and imaging fees, explained Grace Terrell, MD, CEO of Envision Genomics and a member of the PTAC preliminary review team, a three-person group responsible for the initial review of the proposal.

Notably, the target price would exclude drug costs.

This was an important part of the plan in that it removes a key reason oncology practices in the previous Oncology Care Model were unable to hit their targets, McAneny stressed. It also should reassure the Centers for Medicare and Medicaid Services that oncologists would not be incentivized to prescribe a certain drug to get a better cost margin, or avoid a pricey agent that might cause them to miss their cost target, she said.

Each OPC assignment is tied to a “virtual account” that tracks cancer costs, Terrell said. If a patient’s costs fall below the target, any practice participating in the model would share in the savings, assuming certain quality benchmarks — based on patient and family surveys; compliance with certain care pathways — are met.

A 4% quality withhold from all evaluation and management payments is used to form a quality pool. Participants must meet the 80% threshold for both surveys and compliance with care pathways.

Terrell noted some of the PTAC reviewers concerns, including that the OPC targets are not currently operational and designing them is a “time-intensive” process. The OPC is being developed using a machine learning algorithm and the IOBS submitted its proposals based on “proof of concept.”

The reviewers also expressed reservations about the generalizability of the model, and its results, if they’re based on the use patterns of a select practices’ “benchmarks and classifications” that “may not be representative for broad scaling,” according to Terrell.

Asked about the challenge of generalizing the model, McAneny stressed the importance of explaining the statistical aspects of the model “in English” to non-statistician oncologists.

“I think that once physicians see that the targets are accurate, and the prices are fair, and that it’s a model in which they have a chance of success, that they will be very excited about participating,” she said.

The reviewers questioned the flexibility of the model as one factor for quality measures is based on compliance with care pathways (evidence-based guidelines). Paul Casale, MD, MPH, interventional cardiologist and executive director for NewYork Quality Care, also noted that this way of measuring quality might elicit concerns over “cookbook medicine.”

The Vote

As part of the new PTAC two-part voting system, the committee had the option in its first vote to recommend the proposal, not recommend it, or refer it “for other attention” to HHS.

The first vote was unanimous in favor of recommending the model, which triggered a second vote, allowing the committee to provide a more precise recommendation. Six committee members voted to implement the model as specified by PTAC comments, and one member voted to test the model to inform payment.

Terrell said while she viewed the model as “potentially transformative,” she voted for testing rather than development and implementation because of her concerns about the generalizability of the model.

But she praised IOBS, telling MedPage Today “these guys are gonna do well, because they’ve thought very deeply about [the model].” In testing the model and working closely with CMMI, IOBS can identify “inflection points” that need attention and can make the model more broadly successful, she noted.

Bruce Steinwald, MBA, a former director for Health Care Issues at the Government Accountability Office, voted for full implementation of the model “as specified,” but also expressed some doubts, adding that someone within CMS, or an outside consultant, should review the data tables to ensure that proof of concept has been demonstrated.

Other PTAC News

HHS and CMMI are not required to follow PTAC recommendations. Tensions grew between PTAC and the administration in June after Alex Azar, HHS secretary, issued a letter that ignored all of its recommendations. Instead, Azar said HHS would come up with its own models internally.

In September, PTAC leaned on CMMI and HHS to act on its recommendations before the end of 2018; some members threatened to quit PTAC if no action was taken.

Bailet said there are currently three alternative payment models making their way through CMMI’s approval process, and that he anticipates that the models will be introduced in the first quarter of 2019.

PTAC Vice-Chair Elizabeth Mitchell left in September, as did Robert Berenson, MD, an institute fellow for the Urban Institute. Berenson’s term was scheduled to end that month.

Two new members were introduced at the meeting Monday: Angelo Sinopoli, MD, chief clinical officer for Prisma Health, and emergency medicine physician Jennifer Wiler, MD, MBA, of the University of Colorado School of Medicine in Denver. Both have been appointed to 3-year terms.