Medicare Compliance & Reimbursement

Will the OCM overwhelm practices already overburdened by too many APMs?

The much-anticipated Oncology Care Model (OCM) is off and running, with nearly 200 physician practices jumping on board. And the OCM’s goals and promised incentives look enticing for providers.

On June 29, the U.S. Department of Health and Human Services (HHS) announced it selected 196 physician group practices and 17 health insurance companies to participate in the new OCM. The Medicare part of the OCM includes more than 3,200 oncologists and will cover 155,000 beneficiaries across the United States.

This is double what the Centers for Medicare & Medicaid Services (CMS) anticipated as the number of physician participants for the OCM.

Model’s Focus Goes Beyond Chemo

Need to know: The model is specific to patients with a cancer diagnosis who are undergoing chemotherapy treatment, according to Jim Rogers, RN, BSN, director of healthcare solutions at Persistent Systems. The OCM focuses on the key components of care coordination and patient engagement, 24/7 patient access to the clinical team, and incentives for efficient, high-quality care.

The OCM runs from July 1, 2016 through June 30, 2021 and is part of HHS’ overarching goal of transitioning Medicare from volume- to value-based reimbursement. The OCM is a patient-centered care model that “encourages greater collaboration and information sharing so that cancer patients get the care they need,” HHS Secretary Sylvia Burwell said in the June 29 announcement.

The OCM is one of the first CMS physician-led specialty care models, encouraging practices to improve care quality and reduce costs through episodic and performance-based payments that reward high-quality care. Practices may receive performance-based payments for episodes of care surrounding chemotherapy administration and a monthly care-management payment for each beneficiary.

The OCM’s two-sided risk track will be an Advanced Alternative Payment Model (APM) that falls under the recently proposed Quality Payment Program, which stems from provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The Centers for Medicaid and Medicare Innovation (CMMI) sponsors the OCM.

Practices Still Get FFS Payments

The OCM will target Medicare beneficiaries who are receiving chemotherapy treatment and the spectrum of care that participating physician groups provide to the patient during a six-month episode following the start of chemotherapy. The model will cover nearly all cancer types.

Episodes will begin on the date of an initial chemotherapy administration claim or an initial Medicare Part D chemotherapy claim. The episode won’t include services provided prior to that date, but it will include all Medicare Part A and B services that fee-for-service (FFS) beneficiaries receive during the episode period, along with certain Part D expenditures.

The episode will then terminate six months after a beneficiary’s chemotherapy initiation. If a beneficiary continues to receive chemotherapy after the end of an episode, a new six-month episode will begin.

The OCM will utilize a two-part payment approach as follows:

1. Monthly payment — Participating practices will receive a monthly $160 per-beneficiary care-management payment for Medicare FFS beneficiaries. The per-beneficiary per-month (PBPM) payment for enhanced services will provide practices with financial resources to help in effectively managing and coordinating care for beneficiaries.

2. Performance-based payment — Participating practices will also receive a performance-based payment for OCM episodes. This potential for a performance-based payment will incentivize practices to improve care while lowering the total cost of care over the six-month episode periods. CMS will determine the performance payment based on the practice’s achievement and improvement on quality measures.

Participating practices will continue to receive regular Medicare FFS payments during the five-year model. CMS will calculate the performance-based payments retrospectively after the completion of a six-month episode.

CMS Has a Laundry List of Expectations

Most of the services that CMS expects participating practices to provide under the model center on care coordination activities. CMMI laid out specific requirements for participation in the OCM. To participate in the model, physician practices must furnish chemotherapy treatment, as well as:

• Provide the core functions of patient navigation;
• Document a care plan containing the 13 components in the Institute of Medicine (IOM) Care Management Plan outlined in the IOM report, “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis,” which include:

         1. Patient information,
         2. Diagnosis,
         3. rognosis,
         4. Treatment goals,
         5. Initial plan for treatment and proposed duration,
         6. Expected response to treatment,
         7. Treatment benefits and harms,
         8. Quality of life/experience,
         9. Responsibility for patient care,
         10. Advance care plans,
         11. Cost of cancer treatment,
         12. Psychosocial health needs, and
         13. Survivorship plan;

• Provide 24-hours-a-day, seven-days-a-week patient access to an appropriate clinician who has real-time access to the practice’s medical records;
• Treat patients with therapies consistent with nationally recognized clinical guidelines;
• Attestation and use of Office of the National Coordinator for Health Information Technology (ONC)-certified electronic health record (EHR);
• Use data to drive continuous quality improvement, and ensure that data from scans, blood test results, and other tests are received in advance of patient appointments so that patients don’t need to schedule additional visits;
• Coordinate appointments with providers within and outside the oncology practice to ensure timely delivery of diagnostic and treatment services;
• Arrange for diagnostic scans and follow up with other medical team members such as surgeons, radiation oncologists, and other specialists who support the beneficiary through cancer treatment; and
• Provide access to additional patient resources, such as emotional support groups, pain management services, and clinical trials.

All these activities are centered around the patient, as well as the navigators, or coordinators, and caregivers who are guiding the patient on this journey, Rogers says. Key activities include not only the 24/7 patient access, but also social services coordination, referral management, shared decision-making, and patient outreach and education.

Not Everyone is Delighted with OCM Rollout

Although stakeholder responses to the OCM have been largely positive, there are some concerns. For instance, the Community Oncology Alliance (COA) wants CMS to include all of the OCM practices initially in the Alternative Payment Model (APM) arm, along with practices participating in the Oncology Medical Home (OMH) models.

In the recently published proposed rule on the Merit-Based Incentive Payment System (MIPS) and APM, the OCM “would not be available for consideration as an advanced APM until 2018,” Community Oncology Alliance (COA) President Bruce Gould, MD wrote in a June 27 letter to CMS Acting Administrator Andy Slavitt. “This means that practices which have been accepted into the OCM must run concurrent programs for 2017, utilizing MIPS for program participation while implementing OCM.”

“It is entirely unrealistic that CMS asks community oncology practices already overburdened with patient care, other mandatory healthcare reform initiatives, reimbursement cuts, and sequestration, to absorb yet another exorbitant cost of ramping up their clinics for both MIPS and OCM,” Gould stated.

Resources: To find out more about the OCM, visit http://innovation.cms.gov/initiatives/Oncology-Care/. For more information on the newly proposed Quality Payment Program, go to www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program.html.