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Oncology Care Model
July 05, 2016
Overview The CMS Oncology Care Model (OCM) is an innovative, multi-payer model focused on providing higher quality, more coordinated oncology care. Under OCM, physician group practices have entered into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients. The practices participating in OCM have committed to providing enhanced services to Medicare beneficiaries, such as care coordination and navigation, and to using national treatment guidelines for care. OCM is a five-year model that begins on July 1, 2016, and runs through June 30, 2021.
After an open application and selection period, nearly 200 physician groups and 17 payers, in addition to CMS, are participating in OCM. Practice participants are Medicare-enrolled physician groups identified by a single Taxpayer Identification Number (TIN) and composed of one or more physicians who treat Medicare beneficiaries diagnosed with cancer. Participating practices cover urban, suburban and rural areas and range in size from solo oncologists to large practices with hundreds of providers. Other payers are commercial insurers that will align their oncology payment models with Medicare’s model and support OCM practices in their practice transformation efforts. The names of those practices and payers participating in OCM can be found on the OCM website: http://innovation.cms.gov/initiatives/Oncology-Care/.
Background Cancer is one of the most common and devastating diseases in the United States: more than 1.6 million people are diagnosed with cancer each year in this country.1 A significant proportion of those diagnosed with cancer are over 65 years old and Medicare beneficiaries. Through OCM, CMS, in partnership with oncologists, other providers, and commercial health insurance plans, has the opportunity to support better quality care, better health, and lower costs for this medically complex population. This model is part of the Administration’s “Better, Smarter, Healthier” approach to improving our nation’s health care and setting clear, measurable goals and a timeline to move the Medicare program -- and the health care system at large -- toward paying providers based on the quality, rather than the quantity of care they give patients.
Model Design OCM aims to promote whole practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy. The model intends to improve health outcomes and produce higher quality care at the same or lower cost to Medicare. Financial incentives for appropriate care should improve quality and reduce health care expenditures as participating practices address the complex care needs of the beneficiary population receiving chemotherapy treatment, increase their use of high-value services, and decrease their use of unnecessary services.
Participants and Practice Requirements OCM focuses on Medicare FFS beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy. OCM participants are Medicare-enrolled physician groups (including hospital-based practices) that furnish chemotherapy treatment. In addition, OCM participating practices must:
Provide enhanced services, including:
The core functions of patient navigation;
A care plan that contains the 13 components in the Institute of Medicine Care Management Plan outlined in the Institute of Medicine report, “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis”;2
Patient access 24 hours a day, 7 days a week to an appropriate clinician who has real-time access to practice’s medical records; and
Treatment with therapies consistent with nationally recognized clinical guidelines.
Use data to drive continuous quality improvement.
Use certified electronic health record technology.
Quality CMS utilizes clinical data and quality measures as a key mechanism to verify clinical improvements, assess patient health outcomes and appropriate coordination of care, and ensure continued quality of care for Medicare beneficiaries. CMS will track participant performance on multiple quality domains using patient- and practice-reported measures as well as claims-based measures. Quality measures were selected for OCM across four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety. CMS will provide ongoing feedback to practices throughout the model. In addition, the model uses 12 of these quality measures in the calculation of participants’ performance-based payments.
Multi-Payer Model OCM is a multi-payer model that includes Medicare fee-for-service (OCM-FFS) as well as commercial payers working together to transform care for all patients living with cancer. Although there are differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to practice transformation is consistent across all payers in OCM. OCM payers will align their models with OCM-FFS in the following ways: provide payments for enhanced services and for performance; include patients receiving chemotherapy as a focus of the model; share data with participating practices; and align on a core quality measure set. CMS will provide opportunities for OCM payers to convene regularly throughout the model to share lessons learned on engaging in alternative payment model work that supports oncology practice transformation.
Payments OCM participants receive regular Medicare FFS payments during the model. In addition, OCM-FFS uses a two-part payment approach for participating oncology practices, creating incentives to improve the quality of care and furnish enhanced services for beneficiaries undergoing chemotherapy treatment for a cancer diagnosis. These two forms of payment include: 1) a Monthly Enhanced Oncology Services Payment of $160 per-beneficiary for delivery of OCM enhanced services, and 2) a Performance-Based Payment for OCM Episodes.
The Monthly Enhanced Oncology Services payment for enhanced services provides participating practices with financial resources to aid in effectively managing and coordinating care for Medicare FFS beneficiaries. The potential for a Performance-Based Payment encourages participating practices to improve care for beneficiaries and lower the total cost of care over the six-month episode period. The Performance-Based Payment will be calculated retrospectively on a semi-annual basis based on the practice’s achievement on the OCM Quality Measures and reductions in Medicare expenditures below a target price.
Episode Definition OCM covers nearly all cancer types. OCM-FFS episodes begin on the date of an initial Part B or Part D chemotherapy claim and do not include services provided prior to that date. OCM-FFS episodes include all Medicare Part A and Part B services that FFS beneficiaries receive during the episode period; certain Part D expenditures are also included. Episodes will terminate six months after a beneficiary’s chemotherapy initiation. Beneficiaries who receive chemotherapy after the end of an episode will begin a new six-month episode.
Innovation Center OCM was developed by the Center for Medicare & Medicaid Innovation (Innovation Center), which was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). Congress created the Innovation Center to test innovative payment and service delivery models to reduce program expenditures and improve quality for Medicare, Medicaid, and Children’s Health Insurance Program beneficiaries.