Value-based Arrangements

OCM Nears Its June 30 Conclusion Without Successor in Place

The Oncology Care Model (OCM) that CMS’s Center for Medicare & Medicaid Innovation (CMMI) launched almost six years ago is nearing its June 30 end. And while CMMI introduced its Oncology Care First model in November 2019 with an eye on the OCM successor launching before its predecessor’s end, it is unclear what the program’s status is at this point. OCM participants tell AIS Health, a division of MMIT, that their overall experience has been good as they await next steps from CMMI.

The OCM voluntary pilot started in July 2016 with 17 payers and 196 practices; five payers and 126 practices currently are participating. While it began as a five-year program, CMMI extended it for one additional year in 2020 due to the COVID-19 pandemic. The program reimburses providers for episodes of care in the form of a per-beneficiary per-month payment, as well as a possible performance-based payment, if Medicare expenditures are below a target price for an episode. The amount of the payment is tied to a provider’s achievement on various quality measures. All participants began with one-sided risk but could shift to two-sided risk in 2017. Following the 2018 introduction of an alternative two-sided risk arrangement, starting in January 2020, practices that did not earn at least one performance-based payment had to enter one of the two-sided risk options or leave the OCM. Practices that earned at least one performance-based payment could remain in one-sided risk.

Notion of Value-Based Care Within Life Sciences Is Shifting

The notion of value-based care certainly is not a new one. But the concept of what it involves within the health care system and how it can be measured is undergoing a shift, asserted two industry experts. Life sciences companies in particular have an important role to play to ensure that quality and equity in health care are truly achieved.

A value-based care approach “is not centered around a certain payment model or a certain program demonstration,” maintained Taylor Musser, associate principal in the healthcare transformation practice at Avalere Health. Rather, it’s focused on ways to improve the quality of care, she told attendees at a recent webinar sponsored by Avalere. Such an approach will “encompass what care could be delivered by a provider or health system or the care that is coordinated by health plans. And some of the quality objectives” include “are we getting the clinical outcomes we want, are we improving people’s general quality of life and what they experience day to day, [and do] the services or processes of care…align with clinical practice guidelines, for example? We know there are gaps there.” She stated that “avoiding inappropriate or low-value services…is still a concern in our health care systems.”

Third-Party Care Pathways Gain Steam as Cancer Costs Rise

With the costs of treating cancer patients rising ever higher, payers and providers are increasingly turning to third-party pathways — or treatment protocols designed to provide the optimal therapy regimens — to improve outcomes and reduce excess costs. But not all pathways are created equal, and it’s crucial for oncology drug manufacturers to understand their nuances if they want to ensure their therapies are able to reach the most patients.

Those are the main takeaways from a recent “Meet the Expert” webinar from MMIT, AIS Health’s parent company. “It’s really key to get optimal placement of a brand on a pathway to ensure that patients can have access to these lifesaving therapies,” said Yana Faykina, senior consultant, advisory services at MMIT.

Various Components Play Important Role in Companies’ Definition, Demonstration of Drugs’ Value

As prices for health care services, especially drugs, continue to be under the microscope of public scrutiny, life sciences companies are under pressure now more than ever to make sure that they can demonstrate the value of their products. But this may be easier said than done, as a patient’s perception of value may be quite different than, for example, that of a payer. But these conversations are starting to happen and need to continue to evolve and include all industry stakeholders to truly incorporate value into the equation, say life sciences experts.

According to Daniel C. Lane, Pharm.D., Ph.D., director of US Access Marketing-Customer & Portfolio Value Generation for Bristol Myers Squibb, “Value is something that’s very individualized…If you think about value on a conceptual level, it’s a benefit being received over some type of value-assessment measure…At the elemental level, that’s what we as a life science industry are really trying to understand — how do we communicate that?”

Study: 25% of Medicaid Docs Provide At Least 75% of Care

About a quarter of the practitioners in Medicaid managed care organization networks provide more than three-quarters of the services used by members, according to an article published by researchers affiliated with Yale and Cornell Universities in the journal Health Affairs this month. Experts say that this concentration of care likely limits access to care for members, and health plans need to do more to make sure their networks aren’t made up of so-called “ghost providers.”

The article, which analyzed claims and enrollment data from Kansas, Louisiana, Michigan and Tennessee during 2015-17, found that care delivery is highly concentrated in both primary care and specialists. However, the authors caution that their study of the states “might not generalize nationally” and only studied four specialties.


UnitedHealth Delivers Strong 1Q, Touts MA, Value-Based Growth

Despite variations in care utilization due to COVID-19 that drove up medical costs early in the quarter, UnitedHealth Group reported a strong start to 2022, with financial results exceeding analysts’ expectations driven by outperformance in both the UnitedHealthcare and Optum Health segments. As the company anticipates continued growth in value-based care initiatives and Medicare Advantage enrollment throughout the year, it raised its full-year adjusted earnings-per-share (EPS) outlook by 90 cents to a range of $21.20 to $21.70.

For the three months ending on March 31, the company recorded overall revenues of $80.1 billion, representing a year-over-year increase of 14.2% that reflected double-digit growth at both Optum and UnitedHealthcare. The UnitedHealthcare segment reported $62.6 billion in revenues, up 13.6% from $55.1 billion a year ago, and operating earnings of $3.8 billion, compared with $4.1 billion last year, reflecting the effects of “pandemic-disrupted care patterns,” the company explained in its earnings press release. Revenue for the Medicare & Retirement segment was $29.1 billion, up from nearly $25.5 billion in the first quarter of 2021.

Stakeholders Seek Ways to Accelerate Risk Sharing in MA

Although Medicare Advantage is outpacing other payer types in the move from volume to value, there are still ways the program could hasten the shift to value-based care, experts agreed during a recent panel of the AHIP 2022 National Conference on Health Policy and Government Programs. These range from the increased use of Z-codes to document social determinants of health to the adoption of a Star Ratings measure that would influence more risk sharing between MA organizations and their providers.

According to the Health Care Payment & Learning Action Network survey, which is conducted in partnership with AHIP and the Blue Cross Blue Shield Association, 58% of MA payments to providers in 2020 were through an Alternative Payment Model (APM) such as the Shared Savings Program or an episodic/bundled care payment model, and 29.3% of such payments were for a risk-bearing arrangement. That’s compared with nearly 43% of payments through APMs in Traditional Medicare and roughly 35% in both commercial and Medicaid plans.

Medicare Advantage’s Two-Sided Risk Model Associated With Reduced Acute Care Use

Value-based payment models can significantly lower acute care usage among Medicare beneficiaries, suggested a study of nearly 500,000 Medicare Advantage members published last month in JAMA Network Open. The study, which analyzed data collected between December 2017 and January 2019, was led and reviewed by the Humana Healthcare Research Human Subject Protection Office. (Humana is the second-largest MA insurer in the U.S). MA beneficiaries participating in two-sided risk models had lower rates of hospitalizations, observation stays and emergency department visits compared with fee-for-service (FFS) Medicare enrollees. This effect was particularly striking in avoidable acute care use — the two-sided risk model was associated with a 15.6% reduction in avoidable hospitalizations. Researchers noted a lack of significant differences between FFS and upside-only risk models, which “suggests that downside financial risk may play a key role in effective value-based payment arrangements.”

CMMI Director Shares Vision for More Physician Accountability

Aligning with the Biden administration’s goal of improving health equity, the CMS Center for Medicare and Medicaid Innovation (CMMI) last year unveiled a “strategy refresh” that included health equity as a key objective in testing models of care for Medicare and Medicaid beneficiaries. Another strategic goal was to increase the number of beneficiaries in a care relationship where the provider is accountable for quality and total cost of care, with the objective of having all Medicare beneficiaries aligned with accountable entities by 2030.

Addressing a few recent changes to existing models, CMMI Director Elizabeth Fowler, Ph.D., said the agency’s goal in redesigning the Global and Professional Direct Contracting (GPDC) Model was to reorient it toward provider participants and respond to feedback from stakeholders. The model had been criticized for furthering the privatization of Medicare and allowing for-profit entities to manage fee-for-service (FFS) Medicare beneficiaries without their full knowledge and consent.

Revamped Direct Contracting Model Still Holds Promise for MAOs

After progressive Democratic lawmakers urged CMS to shut down a fee-for-service Medicare model aimed at fostering more value-based care arrangements, the agency’s Center for Medicare and Medicaid Innovation (CMMI) on Feb. 24 unveiled a revamped version that it said more closely aligns with its “vision of creating a health system that achieves equitable outcomes through high quality, affordable, person-centered care.” While the three types of Accountable Care Organizations (ACOs) that may participate starting next year appear to largely mirror the Direct Contracting Entities (DCEs) of the current Global and Professional Direct Contracting (GPDC) Model, CMS aims to ensure that participants in the new model operate as provider-led organizations, have a proven track record of providing care in underserved communities and will not be shifting any enrollees into Medicare Advantage — a key concern expressed by lawmakers and advocates.