Insights into the Oncology Care Model, for Payers

Last summer, the Centers for Medicare & Medicaid Services (CMS) launched a new multi-payer model focused on improving care for Medicare beneficiaries battling cancer. Nearly 200 physician groups and 18 payers, including CMS, are participating in the Oncology Care Model (OCM), which began July 1, 2016, and runs for five years, through June 30, 2021. CMS' goal is to partner with private payers to co-deliver the OCM to achieve improved care delivery on a greater scale, and they will continue to utilize Alternative Payment Models, such as the Comprehensive Primary Care Plus (CPC+) model and the Episode Payment Models (EPMs).

CMS has determined that an OCM episode begins with an initial Part B or Part D chemotherapy claim and concludes six months later. Patients who receive chemotherapy after the conclusion of the episode will start another 6-month episode. Practices must offer patient navigation services, a comprehensive care plan, and 24/7 access to an appropriate clinician who has real-time access to the practice's health records. They must also align treatment with nationally recognized guidelines. Further, practices are required to use data to inform continuous quality improvement and use certified EHR technology.

In addition to regular Medicare fee-for-service payments during the episode, CMS will pay practices $160 per beneficiary per month to support practice enhancements (the aforementioned enhanced services), as well as a performance-based payment calculated upon the completion of each six-month episode. This performance payment is based not only on achievement on the OCM quality measures, but also on keeping Medicare spending below a targeted amount.

As an added incentive, practices participating in the OCM may qualify for payment under the Advanced Alternative Payment Model pathway within the new Quality Payment Program, earning such practices a 5% annual bonus while escaping the daunting Merit-based Incentive Payment System (MIPS). While the OCM begins as an upside-only model, beginning in 2018 providers will also be exposed to downside risk—it is this two-sided nature of the model that helps it qualify as an Advanced Alternative Payment Model.

The intersection of the model's quality metrics and benchmark spending levels exposes a unique challenge. In the OCM, CMS requires practices to "use data to drive continuous quality improvement" and to keep Medicare spending below a target amount. Therefore, practices must have access to data regarding both quality performance and expenditures, including their downstream provider partners.

CMS claims that it will provide regular feedback to practices throughout the model, and it requires participating payers to share data with providers as well. However, many doubt the agency's ability to expedite actionable data, as providers have seen data lags as long as 18 months in other Medicare payment reform programs.

Participating private payers are free to modify CMS' payment amounts and episode definitions, but all payers must align their models in several important ways to ensure a consistent approach to practice transformation. For example, participating payers agree to provide some amount of payment for the enhanced services practices must provide, as well as performance-based payments. In addition, payers must focus their models on patients receiving chemotherapy, share data with participating practices, and align with CMS on a core set of quality measures.

This is where Aver can help. Both payers and providers participating in the OCM, or those who are interested in developing a similar episode-based payment program, cannot increase quality and lower cost without actionable data that illuminates what is happening in each patient's experience with cancer. Aver's Episode Advantage platform gives payers an actual sense of the cost associated with a cancer episode. Additionally, Episode Snapshot uncovers the best oncologists and downstream providers. Finally, Episode Workbench can help payers customize CMS’ episode definitions to align with existing programs or meet other organizational goals. These tools can also ensure that payers meet the CMS requirement to share data with participating providers while facilitating their own analysis and self-driven quality improvement efforts.

Contact us to learn more or schedule a demo.

Market and Policy Strategy Associate
Aver Inc.

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