Oncology Rounds

CMMI outlines potential next steps in oncology payment reform—the Oncology Care First Model

by Deirdre Saulet

With the Oncology Care Model (OCM) set to end in just over a year and a half, we've been wondering when the Center for Medicare and Medicaid Innovation (CMMI) would share its intentions for the next phase of oncology payment reform. We got a glimpse on Friday, November 1, when CMMI published an informal RFI on the Oncology Care First (OCF) model. With comments on this model due by December 13, interested stakeholders don't have time to waste, but the good news is that it's only 12 pages long. Read our quick take below and submit your comments ASAP.

Dec. 19 webinar: What you need to know about CMS's radiation oncology model

OCF would replace OCM in 2021

The OCF would start January 1, 2021, and run for five years. Similar to the OCM, it would include six-month episodes of care. While the OCM doesn't end till June 30, 2021, there would be no new OCM episodes initiated during the overlapping months.  

Overall, the model is fairly similar to the OCM, although CMMI says it wants to address the major issues with the OCM's methodology and design. Without seeing all of the finer details of the OCF, the biggest change is the addition of a prospective population payment each month that would include payment for evaluation and management (E&M) services, drug administration, and enhanced services (e.g., navigation). Unsurprisingly, CMMI is also signaling its intent to get more providers to more quickly take on two-sided risk in this model.  

Payment

CMMI proposes two components of payment based on two different populations:

  1. Prospective monthly population payment (MPP): Essentially, this prospective payment would "bundle" reimbursement for E&M visits, drug administration, and enhanced services (e.g., navigation). Notably, this population of assigned beneficiaries is based on an E&M visit with a medical oncologist, so it would include patients receiving chemotherapy and hormonal therapy only, along with patients who are not receiving any cancer-related drugs, such as survivors, who are still seeing their medical oncologist as part of follow-up care. The payment would be determined based on:
    1. Median national historic payments;

    2. A participant-specific adjustment accounting for an organization's volumes, case mix, and risk stratification, which would stratify a subset of tumor sites into high (e.g., receiving chemo), low (e.g., hormone therapy only), and no chemo/hormone therapy; and

    3. Enhanced services payment.

    The MPP would be calculated prospectively.

    Note: Including this broader population of patients based on an E&M visit with a medical oncologist and not receiving any drug therapy is a big change from the current population included in the OCM.

  2. Total cost of care: Providers are on the hook for total costs over the six-month episode period, including drug costs. Providers have the opportunity to achieve a performance-based payment (PBP) or owe a repayment to CMS (PBP recoupment), depending on quality performance and costs relative to benchmark and target amounts. This is a different population from the population above—this is just Medicare fee-for-service (FFS) beneficiaries receiving Part B or D chemotherapy, not including hormonal therapy, for a cancer diagnosis of any stage.

  3. Note: This component is fairly similar, without knowing the finer details, to the OCM.

Risk

CMMI calls out three risk tracks in the RFI, including an option for upside-only available for the first two performance periods of the OCF Model, and two tracks with two-sided risk. The first of the two-sided risk tracks would be a less aggressive option than the second.

The potential OCF Model would require all physician group participants that participated in OCM to be in two-sided risk for the full duration of their participation in the OCF Model. But CMMI is currently considering letting participants who did not participate in OCM to continue with no downside risk for a limited time.

Participants

Physician group practices and hospital outpatient departments (HOPDs) that are paid under the Hospital Outpatient Prospective Payment System (HOPPS) could participate. As with all other CMMI- and CMS-proposed models, this excludes organizations that are paid under a different methodology, such as the PPS-exempt cancer hospitals.

Importantly, the RFI notes that any HOPD that provides chemotherapy or chemotherapy services for 25% or more of a participating physician group's attributed episodes would need to voluntarily participate in a group with the physician practice. HOPD participants would receive the monthly population payment rather than separate Medicare FFS payments for claims for drug administration and E&M services for HOPD-assigned beneficiaries.

Enhanced services and quality measurement

Similar to OCM, the OCF would require participants to provide enhanced services. The first six are the same as the OCM:

  1. Offer beneficiaries 24/7 access to a clinician with real-time access to their medical records;

  2. Provide the core functions of patient navigation;

  3. Document a care plan for beneficiaries that contains the 13 components of the Institute of Medicine's (IOM) Care Management Plan;

  4. Treat beneficiaries with therapies consistent with nationally recognized clinical guidelines;

  5. Use Certified Electronic Health Record Technology (CEHRT) as specified in regulation;

  6. Utilize data for continuous quality improvement; and

  7. Gradually implement electronic patient-reported outcomes (ePROs).

They also propose keeping the current OCM quality measures consistent.

Get your comments in

You've got only a few weeks to get your comments in! Submit them by December 13 to OCF@cms.hhs.gov.

5 imperatives for your new cancer program investment strategy

Now more than ever, cancer programs need to balance their operational and financial realities with the desire to provide patients with the latest and greatest treatments and technologies.

This infographic covers five imperatives and questions that will ensure your investments have a significant impact on your patients and maximize your financial return.

Download Now