Nearly 200 oncology practices are one-quarter of the way through their five-year journey with the Center for Medicare & Medicaid Innovation (CMMI) to test a new model for cancer care delivery and reimbursement. The Oncology Care Model (OCM) was designed to improve care coordination, access, and appropriateness while lowering the total cost for Medicare beneficiaries receiving cancer treatment.
Now more than 16 months into the pilot, participating practices point to a number of successes attributable to OCM, even as they grapple with challenges presented by the model.
Participation in OCM has pushed cancer practices to think more holistically about their costs and refine their programming to deliver the highest-quality patient experience possible. Additionally, the new model is propelling them to develop strategies and tactics that will be useful in the future of value-based payment.
Financial Benefits: Cancer programs that previously tried to improve care quality faced a dilemma: improved outcomes might reduce patient revenue. OCM accounts for that, providing a payment to offset lost revenue and rewarding providers who reduce avoidable healthcare utilization such as emergency room visits. Moreover, OCM practices can utilize funding received from the per member per month payment (called a Monthly Enhanced Oncology Services [MEOS] payment) to support program development, such as nurse navigation and quality improvement. While the immediate financial benefits may be small, practices are putting important infrastructure in place to succeed in a changing reimbursement environment that prioritizes value over volume.
Impetus for Change: Some participating providers have noted that many of the investments required for OCM will be needed in the future of value-based care. One common example is the formation of a multidisciplinary cancer leadership team that oversees OCM requirements and monitors practice transformation efforts. Collaborative teams of this nature have recommended significant changes within their practices to enhance patient care, improve care quality, and maximize available resources.
Patient Alignment: Many OCM initiatives align provider and patient interests. Practices have embarked on numerous initiatives that cancer patients appreciate and find useful, such as:
- Implementing care management programs, including adding navigators and making treatment planning discussions routine.
- Increasing the use of palliative care and hospice services.
- Offering patients streamlined financial counseling.
- Increasing access through the development of a 24/7 cancer clinic or an after-hours oncology nurse call system.
Reimbursement for care coordination, focused treatment planning, and improved access has typically been absent from the fee-for-service payment system. OCM is enabling providers to offer these services without fear of lost time and revenue.
Selection of EMR: Some providers have determined that by switching to an EMR that better aligns with the requirements of the OCM program, they can reduce data collection and reporting burden. Other OCM practices have learned how to maximize the functionality of their existing EMRs to develop automated reports or dashboards that show them how well they are performing on clinical measures and allow for a more in-depth and individual look at cancer patients over time.
As with any new payment model, OCM has presented its share of challenges as providers adapt to new expectations and requirements. Providers in OCM practices have been vocal about the bumps in the road they’ve encountered—and it is extremely important for this feedback to continue so that CMMI can adjust and improve the program.
Measure Reporting: Staff burden for measure reporting can be significant. CMMI had to scale back quality data collection after feedback from participants indicated that it was difficult to automate and required substantial resources to implement. Despite CMMI’s modification, meeting the extensive data collection and reporting requirements continues to be a strain for many practices, especially those that lack a sophisticated EMR or dedicated analysts.
EMR Use: Many participating providers have indicated that their current EMRs do not have solutions optimally designed for OCM. Some EMRs have limited reporting capabilities, requiring manual data abstraction and extensive time involved sorting, filtering, and verifying information. In general, providers must spend significant time learning new systems and how they can support OCM reporting.
Billing Timing: Some organizations have reported that billing issues with CMS have led to MEOS revenue lagging behind necessary investments—creating issues for OCM practices that rely on this additional funding to finance these investments. Moreover, the shared savings payment from the reduction in total cost is a retroactive payment that practices may not receive for at least a year.
Data Analysis: CMS provides organizations with a significant amount of beneficiary data as part of the program. But how much is too much? Practices have struggled to keep up with the constant influx of information, have been unable to quickly and usefully analyze the data, and aren’t always sure about what information is relevant. Some providers are also unclear on how to effectively use the data to identify financial opportunities, reduce overall costs, or implement QI initiatives. Other OCM practices face challenges in using their data to analyze compliance with clinical guidelines.
Target Pricing: Episode prices are variable and depend on a variety of patient characteristics. It is difficult for organizations to predict what a target episode price will be, even within a specific tumor site. CMMI has acknowledged that the current target pricing model is imperfect because the risk-adjustment methodology is only based on factors that can be found in claims data. For example, key clinical information, such as cancer stage, is excluded. This lack of data will continue to limit the model’s predictive power, although CMMI is in the process of collecting clinical data from OCM practices to improve its risk-adjustment approach.1
Episode Identification: Determining the start of a treatment episode for oral oncolytic patients has proved to be a challenge because some providers cannot easily obtain medication adherence information to determine their OCM eligibility. In particular, cancer programs that do not have their own retail or specialty pharmacy have dealt with the time-consuming process of tracking down fill data information from local or mail order pharmacies.
Physician Engagement: OCM requires physician buy-in and behavior change. Some OCM administrators explain that physicians support the program in concept, but not always in participation and process compliance (e.g., poor clinician EMR documentation continues to be a challenge for many participating practices). Adherence to OCM will require both administrators and physicians to be supportive of initiatives such as improved EMR documentation standards, increased workload for compliance, and patient work flow changes.
OCM continues to be a model in progress. Participating practices are learning from one another the specific tools and resources that can be implemented to ensure successful participation and overcome barriers.
Given that OCM is a pilot, we can expect adjustments and concessions along the way. OCM practices’ feedback to CMS is helping create changes to the program, and will be adapted to future payment models as well. Even if OCM does not prove to be the payment model solution for cancer care, its learnings will undoubtedly increase providers’ preparedness as reimbursement continues to evolve and change.
Polite, B and Walradt, J: Pursuing Value in Cancer Care: A Model in Progress. Journal of Oncology Practice 13:7, 407-409, 2017.