CMS Innovation: The Oncology Care Model

Oncology Care ModelBy Sarianne Gruber
Twitter: @subtleimpact

The Centers of Medicare and Medicaid Innovation (CMMI) introduced its Oncology Care Model (OCM), an innovative new value-based care, payment model this past February 2015. This the second specialty new payment and delivery care model. (The first is the End Stage Renal Disease model). These new CMMI models are being designed for both primary and specialty care practices. The Innovation Center was mandated by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act), and was put into effect by Congress to test innovation payment and service delivery models with the purpose to reduce CMS program spending and improve quality for patients. The OCM targets cancer treatments that are medically complex, and has an extremely high cost of for its population. The model emphasizes practice transformation to improve care coordination and enhance patient care. Practices and payers will enter into payment arrangements that include financial and performance accountability for episodes of care for chemotherapy administration. The OCM will allow the opportunity for practices administering chemotherapy to share in cost savings while improving care quality. Practices are requested to submit letter of intent by April 23 and a final application is due on June 18. The CMMI is anticipating to have 100 practices participate for a 5 year period beginning in spring 2016.

The Oncology Care Model

The OCM is a multi-payer model that includes Medicare fee-for-service and seeks other payers to be included model such as commercial insurance plans or state Medicaid. Though the selection of quality measures for performance-based payment may vary by payer. The OCM model operates concurrently with the Medicare’s fee-for-service (FFS) reimbursement system for cancer care. The OCM will cover nearly all cancer types. Centers will continue to receive standard Medicare FFS payments. The cancer model specifically pertains to those patients receiving chemotherapy agents i.e. trastuzumab, axitimib and others. The model uses financial incentives, including performance-based payments. Hopefully, these payments will encourage a decrease in expenditures as practices meet the complex needs of cancer patients on chemotherapy treatments.

A two-part payment incentive plan:

  • A per-beneficiary per month (PBPM) payment of $160 for Medicare FFS beneficiaries for an entire chemotherapy episode, which is a six month period and is renewable. The PBPM payment provides financial resources to assist practices in managing and coordinating care for each Medicare FSS patient.
  • A performance-based payment for OCM episodes of cancer care. This is aimed to incentivize participating practices to improve patient care and lower the total cost of care over the 6-month episode period. The amount of performance-based fee payment is contingent on how well the practice improves select quality metrics, such as those of the National Quality Forum. Performance-based payments will be calculated retrospectively after the completion off a 6-month episode.

Participation Requirements

Physician practices that administer chemotherapy may participate in the OCM. These practices will need to target and track beneficiaries receiving chemotherapy and medical treatment for cancer. The prerequisites are:

  • Provide clinicians with 24 hours a day, 7 days a week real-time access to medical records
  • Use an ONC certified EHR
  • Attest to in the Meaningful Use Stage 2 program by the end the third OCM year
  • Provide complete and comprehensive care functions for patient navigation
  • Have a documented care plan covering 13 components of the Institute of Medicine (IOM) Care Management Plan for every patient
  • Treat patients with therapies consistent with nationally recognized clinical guidelines.

For information about the model or the application process, details can be found on the CMS Oncology Care Model Fact Sheet and the Oncology Care Model External FQAs.