The Center for Medicare and Medicaid Innovation (CMS Innovation Center or CMMI) is continuously developing new payment and delivery models designed to improve the effectiveness and efficiency of both primary and specialty care. Among those specialty models is the Oncology Care Model, an innovative new payment model for physician practices administering chemotherapy. Under the Oncology Care Model (OCM), practices and payers will enter into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients, and will allow the opportunity to share in cost savings while improving care quality. Participation in the OCM will be determined through a competitive application process. Interested practices must submit a letter of intent (LOI) this month (by April 23, 2015), followed by full applications on June 18, 2015. The Innovation Center hopes to have 100 practices participate in the OCM over a planned 5 year period beginning in Spring 2016.
The Oncology Care Model was developed by the Center for Medicare and 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 CMS program expenditures and improve quality for CMS beneficiaries.
Why participate in the OCM?
The overarching aims of this OCM model are to improve health outcomes for patients with cancer, improve the quality of cancer care, and reduce spending for cancer treatment. This is often referred to as the “triple aim”: better care, smarter spending, and healthier people, which the Innovation Center is particularly targeting in cancer patients given that they comprise a particularly medically complex and high cost population. The model emphasizes that practice transformation is required to improve care coordination and enhanced patient care. CMMI outlines many key opportunities within the OCM, including improved shared decision-making and patient-centered communication, reductions in complications of cancer and cancer treatments including emergency department (ED) visits and hospitalizations, continuously quality improvement and reporting. A key component of participation in the OCM is that every patient participating in the OCM must have a documented care plan covering the 13 components within the Institute of Medicine (IOM)’s Care Management Plan.
CMMI expects that physician practices selected for participation in the model will be able to transform care delivery for patients undergoing chemotherapy, leading to improved quality of care for beneficiaries at a decreased cost to payers. Through this care transformation, practices participating in OCM-FFS (fee-for-service) can reduce Medicare expenditures while improving cancer care for Medicare FFS beneficiaries. Participating payers will have the opportunity to further these goals for their own beneficiaries who are cared for by practices participating in OCM.The OCM is intended to be a multi-payer model, and thus Centers for Medicare and Medicaid Services (CMS) is also seeking the participation of other payers in the model. Other participating payers will share in the Innovation Center’s opportunity to realize cost savings and improve care This model aims to provide higher quality, more highly coordinated oncology care at a lower cost to Medicare.
How does the OCM work?
It’s important to understand that the OCM is a model that operates on top of Medicare’s current fee for service (FFS) reimbursement system for cancer care (centers will continue to receive standard Medicare FFS payments as well), and specifically pertains to those patient receiving chemotherapy agents, broadly defined to include targeted therapies such as trastuzumab, axitinib, and others. The OCM provides practice support and incentives to improve the quality of care through two mechanisms: 1) a monthly per-beneficiary-per-month (PBPM) payment for the duration of each chemotherapy episode, and 2) a performance-based payment for associated episodes of cancer care. Episodes of chemotherapy are defined as 6 month periods of time and are renewable, and Medicare pays the oncology practice a monthly PBPM care coordination or care management fee for each of the 6 months within a given episode. Practices will receive $160 a month for each patient for the duration of the chemotherapy episode of care, a fee intended to assist practices in managing and coordinating care for these patients.
The performance-based fee payment is intended to be the major financial incentive for practices to improve care quality and reduce cost. In essence, practices will be financially rewarded if they demonstrate cost savings below the target price for each 6-month chemotherapy episode, and the amount of the performance-based fee payment will be further determined by the degree to which certain “performance multipliers” are met, including achievement of quality metrics and performance measures that CMMI has determined to represent a higher level of care coordination or care management. These metrics include certain established quality measures, such as those of the National Quality Forum (NQS). Physician practices are also required to engage in practice transformation to improve the quality and coordination of care for cancer patients, which also entails:
- 24/7 patient access
- Use of a certified EHR and participate in the meaningful use program
- Patient navigation services and delivery of care plans that meet industry standards
Community Oncology Alliance (COA) Director, Ted Okon, believes this is this “is a step in the right direction. I commend CMMI. They listened. We had a lot of physicians involved. They talked with us, they met with us. The idea of paying a care coordination or management fee and also having a performance fee that is based on quality and then on cost is very much along the lines of what is the COA model for community cancer care.”
What must practices do to participate?
OCM will target beneficiaries receiving chemotherapy treatment and the spectrum of care provided to a patient during a 6-month episode following the start of chemotherapy. Physician practices that furnish chemotherapy treatment may participate in OCM. In addition, in order to participate in OCM, practices must:
- Provide the core functions of patient navigation;
- Document 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” (See Appendix A below);
- Provide 24 hours a day, 7 days a week patient access to an appropriate clinician who has real-time access to practice’s medical records;
- Treat patients with therapies consistent with nationally recognized clinical guidelines;
- Use data to drive continuous quality improvement; and
- Use an ONC-certified electronic health record and attest to Stage 2 of meaningful use by the end of the third model performance year.
Carevive Health Offers a Solution
Carevive Health, Inc. provides technical infrastructure and software services to help cancer centers meet OCM requirements. The OCM requires that practices use tools to help improve patient engagement and care coordination. Specifically, the OCM requires participating practices ensure that patients are engaged in the development of a care plan specific to their preferences, concerns, and needs. As presented at the American Society of Clinical Oncology (ASCO’s) Quality Care Symposium in October 2015, Carevive’s Care Planning System (CPS™) improves patient-centered communication (Brant et al., 2015). We also demonstrated the feasibility of integrating our care planning technology into clinic workflow, resulting in high levels of clinician satisfaction.
Our technology includes a patient-reported outcomes and care planning platform that is cloud-based, HIPAA compliant, and directly helps centers to achieve the 13 components outlined in the IOM Care Management Plan (see Appendix A). Research experts have worked with Carevive Health to formulate patient questions to efficiently and effectively understand patient’s treatment goals and their symptom experience. These data are then used to draft personalized, patient-facing care plans that educate patients about their treatment plan, expected benefits and harms.
The care plans can also include personalized, evidence-based supportive care needs, including genetic counseling, fertility preservation, and psychosocial and physical symptom management recommendations, and with whom the patient could engage to complete. Care plans can be given throughout the cancer continuum from diagnosis to survivorship.
Contact Carevive Health to request a demo if your health system plans to pursue the Oncology Care Model.
Appendix A: Components of the Institute of Medicine Care Management Plan
- Patient information (e.g., name, date of birth, medication list, and allergies)
- Diagnosis, including specific tissue information, relevant biomarkers, and stage
- Treatment goals (curative, life-prolonging, symptom control, palliative care)
- Initial plan for treatment and proposed duration, including specific chemotherapy drug names, doses, and schedule as well as surgery and radiation therapy (if applicable)
- Expected response to treatment
- Treatment benefits and harms, including common and rare toxicities and how to manage these toxicities, as well as short-term and late effects of treatment
- Information on quality of life and a patient’s likely experience with treatment
- Who will take responsibility for specific aspects of a patient’s care (e.g., the cancer care team, the primary care/geriatrics care team, or other care teams)
- Advance care plans, including advanced directives and other legal documents
- Estimated total and out-of-pocket costs of cancer treatment
- A plan for addressing a patient’s psychosocial health needs, including psychological, vocational, disability, legal, or financial concerns and their management
- Survivorship plan, including a summary of treatment and information on recommended follow- up activities and surveillance, as well as risk reduction and health promotion activities