Earlier this month, the Center for Medicare and Medicaid Innovation (CMMI) at CMS distributed a preliminary design paper for a chemotherapy episode-based oncology payment model.
The proposal, called the Oncology Care Model (OCM), aims to deliver improved health outcomes at a lower cost by focusing on care coordination, access to care, and delivery of appropriate clinical care.
A three-part payment structure
While CMMI has not finalized the model, the design paper provides an anticipated payment structure for an episode—currently defined as six months following a beneficiary’s chemotherapy initiation.
The three key elements are:
- Traditional fee-for-service (FFS) payments for Medicare Part A, B, and D services
- A per-beneficiary per-month (PBPM) payment intended to finance the care transformation requirements
- A retrospective risk-adjusted, performance-based payment that is based on the difference between the expected costs and the actual costs, and also depends on performance on quality metrics
Eight quality metrics intended for determining performance payments
OCM includes a performance-based payment that is adjusted according to achievement along eight proposed quality metrics, listed in the table below.
Related: Cancer Quality Dashboards
CMMI has selected several widely-recommended metrics relating to palliative care, as well as patient satisfaction and distress screening measures. Additionally, CMMI will monitor quality with another twenty-four metrics that will not be factored into the performance payment calculation.
|Number of emergency department visits per attributed OCM-FFS beneficiary per OCM-FFS episode
|Number of hospital admissions per attributed OCM-FFS beneficiaries per OCM-FFS episode
|(NQF #0216) Percentage of all Medicare FFS beneficiaries managed by a practice who are admitted to hospice for less than 3 days
|(NQF #0211) Percentage of all Medicare FFS beneficiaries managed by a practice who experience more than one emergency department visit in the last 30 days of life
|(NQF #2100) Percentage of attributed OCM-FFS beneficiary face-to-face encounters with the participating practice in which there is a documented plan of care for pain AND pain intensity is quantified
||Reported by practice
|Score on patient experience survey (CAHPS as modified by the evaluation contractor)
||Administered by CMS contractor
|Percentage of attributed OCM-FFS beneficiary face-to-face encounters in which the patient is assessed by an approved patient-reported outcomes tool. This would include a minimum of the PROMIS tool short forms for anxiety, depression, fatigue, pain interference, and physical function
||Reported by practice
|Percentage of attributed OCM-FFS beneficiaries that receive psychosocial screening and intervention at least once per OCM-FFS episode
||Reported by practice
Source: CMMI, “Preliminary design for an oncology-focused model” (2014)
Related: Cancer Quality Dashboard Metric Selection Tool
Care transformation is a prerequisite
Participants must engage in practice transformation, and CMMI includes a number of specific requirements, such as employing a patient navigator/care coordinator and providing 24/7 access to clinicians.
As we noted recently, this type of care delivery innovation might present the best opportunity for cost savings in medical oncology episodes.
Other payers are invited to participate in OCM, as CMMI hopes to prevent providers from being penalized for investing in care transformation measures that reduce utilization (and therefore reimbursement under FFS).
As we anticipate the release of the final model and the official Request for Applications, we’re left with several questions about OCM:
- Does CMMI have any plans to use the CAHPS for Cancer Care?
- How will CMMI determine which patients, conditions, and procedures will be included and excluded?
- Can OCM succeed without the participation of other payers?
- OCM includes only one-sided risk for participants in the first year, but will assuming two-sided risk remain optional to participants as they continue participation?
CMMI still seeking feedback
CMMI remains open to input from the oncology community about OCM.
In particular, they have emphasized the need for feedback about additional quality metrics, factors to incorporate in setting prices for chemotherapy episodes (e.g., cancer type, comorbidities, age), and the opportunities and challenges for payers to align with practice transformation and payment structure of OCM.
For more information, read the status page for CMMI’s specialty practitioner payment models, or contact the CMMI team.