In January 2016, the Centers for Medicare & Medicaid Services (CMS) and its Center for Medicare and Medicaid Innovation (CMMI) announced a new value-based payment program for oncology practices and centers. The Oncology Care Model (OCM) is an alternative payment model (APM) that CMS is testing over a 5-year period to evaluate the shift in oncology payments from fee-for-service to fee-for-value.
The OCM will evaluate the total cost of care of cancer patients undergoing chemotherapy during a 6-month episode. Per member per month (PMPM) payments during these episodes will be structured to help the groups meet certain practice requirements, such as 24/7 clinician access and certain patient navigation services. Retrospective, incentive-based payments will be awarded to practices for episodes that perform better against benchmark targets for total cost of care as well as for achieving certain quality measures. In Year 3, practices will have the option to accept downside risk under reduced cost targets.
CMMI has indicated that it will select between 100 to 150 applicants for participation in OCM in March 2016. The number of practices will represent between 10% and 15% of the total number of practices that responded to American Society of Clinical Oncology’s (ASCO’s) 2015 National Oncology Census.1
The results of the pilot will no doubt inform future oncology reimbursement models, leading many physicians and administrators to ask, “what should we do now?” Whether they’re planning to be involved in the OCM project or are considering participation in other APMs, practices need to be putting the necessary building blocks in place to measure quality and the total cost of oncology care. With that in mind, here are five ways practices can start positioning for these changes.
1. Educate physicians and staff.
The first step in successfully adopting any APM is educating the care team on the model’s requirements. For the OCM, CMMI defined six elements that a practice must have in place to participate, including 24/7 access to a triaging clinician, utilization of patient navigators within the practice, and adherence to nationally recognized clinical guidelines. Each of these elements is essential to a high-functioning care team and oncology practice, and many commercial payors require similar elements in their APMs.
2. Build a process or mechanism to identify and track patients through a chemotherapy episode.
Practice administrators will need to work with their clinical and IT resources to build the appropriate identification mechanisms in their EHR and practice management systems. It would also be wise to plan out how the PMPM service will be billed – and how the practice will start tracking total cost of care within these episodes.
3. Start building relationships now.
The oncology practice or center needs to understand and monitor the total cost of care for its chemotherapy patients. The challenge is that typically the medical oncologist is one of many specialists with whom the cancer patient may be interacting on an ongoing basis. Each practice should identify the organizations or providers with which it needs to establish relationships to enable data sharing.
4. Track performance under quality, cost, and outcome measures.
In addition to practice operations and patient process elements, practices must demonstrate adherence to performance standards in several other domains. Certain cost and quality data will be generated from the Medicare beneficiaries’ claims; however, practices will need to track and monitor other aspects of care coordination, such as psychosocial screening and palliative care consultations. Having systems in place to measure these various indicators of high-quality care will be essential.
5. Engage patients to improve accessibility, coordination, and transparency in cancer care.
Communicating and educating patients and their families may be the most important step of transitioning to value. Cancer care is complex; practices must help patients navigate the broad spectrum of services, educating them on both the clinical and financial aspects of care provided. Better informed patients will be engaged decision makers and will help improve outcomes.
Adopting models such as the OCM requires transformational change, and that can be daunting. But the shift to value-based care will only continue, and getting ahead of these changes with a well-conceived strategic plan is essential to any cancer practice’s success. We’ll continue monitoring the OCM’s rollout in this space, so check back for future insights and strategies to address this and other APM programs.
1. The State of Cancer Care in America 2015, ASCO, http://www.asco.org/practice-research/national-oncology-census.