Angela Maas | | July 2016
CMS launched its Oncology Care Model (OCM) on July 1 with 17 health insurers and almost 200 physician group practices. The five-year pilot, which was developed by the Center for Medicare & Medicaid Innovation (CMMI), is focused on providing better quality and more coordinated cancer care for Medicare fee-for-service (FFS) beneficiaries, as well as other payers, but at a lower cost. The Medicare aspect of the model will include more than 3,200 oncologists and cover about 155,000 Medicare beneficiaries, says the agency.
The 196 practices are almost double the number that CMS anticipated would participate in the model, according to Patrick Conway, M.D., CMS acting principal deputy administrator, deputy administrator for innovation and quality, and chief medical officer.
“I was surprised to see nearly 200 practices selected when CMMI announced during the application process that they were seeking only 100,” says Marcus Neubauer, M.D., medical director of oncology services for The US Oncology Network and McKesson Specialty Health. “This tells me that CMS is very serious about the OCM. They want a lot of engagement. They want to generate ‘big data.’ They want to lead the way in data sharing. And they want a substantial group of providers participating to be able to move forward (beyond the model phase) with alternative reimbursement methodologies.”
“The strong participation in the program indicates physicians’ interest in entering into new payment models and experimenting with risk-based payment and also the Medicare program’s interest in expanding delivery reforms into specific disease states,” says Fred Bentley, vice president of Avalere Health’s Center for Payment & Delivery Innovation.
An Avalere analysis of the participants finds that the physician practices are in 31 states. That number, says the company, is actually lower than anticipated based on the letters of intent (LOIs) submitted to CMS, “which showed that physician practices in all but five states were interested in participating in the program.” Neubauer tells SPN this shouldn’t have an impact on the model: “Nearly 200 practices and hundreds of thousands of patients enrolled should negate any geographic concerns.”
Avalere also notes that the states with the highest number of participating providers are Alabama, California, Illinois, New Jersey, New York, Ohio, Pennsylvania and Virginia. Neubauer says he doesn’t think there is anything significant about those particular states. “Of interest, I believe Alabama had 11-12 practices. But I don’t know that this is significant,” he says. “CMS is a federal program, and I think there is enough geographic variance to meet the intended objectives and expected outcomes.”
CMS unveiled the multipayer initiative in February 2015 (SPN 2/15, p. 4). The OCM will reimburse providers for episodes of care in the administration of chemotherapy. “Nearly all cancers” will be included in the initiative, which also will allow beneficiaries to have 24-hour access to providers.
Payments to providers will “include financial and performance accountability,” and OCM has a two-part payment system: (1) a per-beneficiary Monthly Enhanced Oncology Services (MEOS) payment of $160 for an episode’s duration for “effectively managing and coordinating care,” and (2) a possible performance-based payment (PBP) for episodes of care that “will incentivize practices to lower the total cost of care and improve care for beneficiaries during treatment episodes.” The latter payment will be available only for providers who care for people with “high-volume cancers for which it is possible to calculate reliable benchmarks.” CMS estimates that these cancers cover about 90% of Medicare fee-for-service beneficiaries who are getting chemotherapy.
Episodes of care are for six months starting with chemotherapy administration per a Part B claim or an initial chemotherapy claim under Part D and will include all Parts A and B services a beneficiary receives during that period of time, as well as some Part D costs. Subsequent episodes beyond the initial six months are possible as well when beneficiaries continue treatment beyond six months.
Participants must “use therapies consistent with nationally recognized clinical guidelines,” and CMS specifically mentions ones from the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO). “Participants have to document that treatments were in line with NCCN or ASCO guidelines,” Bentley explains to SPN. “In cases where treatment was not within these guidelines, practices will need to provide documented justification for the treatment decision.”
Providers who already have their own pathways established shouldn’t have a problem continuing to use them “because pathways typically are more succinct than guidelines,” says Neubauer. “For example The US Oncology Network’s Value Pathways Powered by NCCN are all contained within NCCN Guidelines and so adhering to Value Pathways Powered by NCCN is also adhering to NCCN Guidelines, by definition.”
CMS also tapped nearly 20 payers to participate in the model, including “some larger-sized payers (e.g., Aetna, Cigna and Highmark) as well as payers that are a part of larger payer networks (e.g., multiple regional Blue Cross Blue Shield (BCBS) payers as part of the Health Care Service Corp. (HCSC)),” points out Bentley. “However, it’s important to note that payer size wasn’t the sole selection criteria since Anthem, Humana and other BCBS payers submitted LOIs but were ultimately not selected.”
In addition, he says, provider-sponsored plans are in the mix, including SummaCare, The University of Arizona Health Plans, HealthPartners, Priority Health and UPMC Health Plan. “Some plans, such as BCBS Michigan, are already heavily invested in APMs [Alternate Payment Models] and would be able to leverage that experience as part of OCM. UnitedHealthcare is already implementing their own oncology bundled payment programs and is not participating in OCM. Aligning the geographic distribution of providers and payers was also a likely selection criteria that CMS used to ensure that providers and payers were aligning incentives through their participation in OCM.”
Payer participants “can create their own incentive structure for physicians in OCM, but they must generally align with the goals of CMS’s incentives program,” Bentley says. “Specifically, they must provide payment during OCM episodes (e.g., an added per-member per-month care management payment) and must set up a system that incentivizes performance. Plans must also create incentives around six practice requirements specified by CMS.
According to Neubauer, “Some payers will work with practices to set up agreements similar to the OCM. However, most will be negotiating agreements that are much simpler (fewer quality metrics and documentation requirements). Financial incentives are meant to be aligned with OCM financial incentives, but we have already seen significant variability so far.”
Asked about the potential benefits of participating in the OCM, Neubauer points out that “providers, particularly in community practices, have struggled with ancillary services that aren’t billable. The OCM allows funding for enhanced services that are meant to improve the patient care experience. So providers participating in the OCM will have the support to improve the patient care experience. Providers will receive robust data from CMS for continuous learning. Providers will be thrust into the leading edge of value-based reimbursement experiments. Being at the table is an advantage, in my opinion.”
In addition, Bentley points out that as proposed under the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA), the OCM will be considered an APM, “meaning participating physicians will be excluded from the Merit-Based Incentive Payment System (MIPS) and will receive higher payment rates from CMS beginning in 2019. Entering into bundled payment programs and transforming practice patterns might be strategically important to physicians looking to continue implementing value-based contracts with payers and generally stay in front of the trend of payments shifting away from FFS.”
And with payer participants, “Payers generally benefit from bundled payment contracts because they give them an opportunity to incentivize cost reduction and quality improvement, and could offer more predictability into medical costs if practices are at risk for meeting established cost benchmarks over episodes of care,” says Bentley. The OCM “provides a clear set of physician practices interested in participating in the model, and payers might also benefit from efficiencies practices are already achieving in the CMS model. The CMS OCM model provides an established quality/incentive framework from which to build on and might also offer name recognition/credibility.”
Potential participation risks for providers include a negative return on investment “if incentive payments do not exceed investments in program participation, and [providers] could lose a substantial amount if they do not succeed under the two-sided risk model,” which begins in the third year of the program, says Bentley.
Neubauer says additional risks for providers include “hiring many new staff and not being able to cover the expense of new staff with OCM funding,” as well as “recoupment of MEOS and PBP if not living up to program requirements. These risks are small, in my opinion, and greatly outweighed by the benefits of being participants in this monumental, transformative program.”
Source: AIS Health
https://aishealth.com/archive/nspn0716-03