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Five Things You Should Know About the Oncology Care Model

By Gena Cook, CEO, Navigating Cancer

2016 promises to be a transformative year for cancer care delivery, with the roll out of the Oncology Care Model (OCM). In a few short months, the Center for Medicare and Medicaid Innovation (CMMI) is expected to announce the 100 participants from the pool of OCM applicants that were submitted last June.

What do cancer centers need to understand about OCM now?

OCM is a payment reform model designed to improve episodes of care for patients undergoing chemotherapy. The goal of this payment model is to promote care delivery at the lowest cost, in the most medically-appropriate setting. An OCM episode of care begins with the initiation of chemotherapy treatment and extends over the following six-month period, but one beneficiary may undergo multiple OCM episodes of care during the five-year OCM performance period. Provider participants will consist of physician group practices, as well as practitioners in solo practice. One key feature of OCM is that it places the medical oncologist in the lead role of managing care quality, delivery and cost. In exchange, providers will earn a management fee of $160 per beneficiary per month. That’s $960 per 6-month episode.

In addition, practices will have the potential of earning an average of 12% shared savings through semi-annual performance-based payments – a figure which could amount to $16,000 per beneficiary per year.

Both of these OCM payments are in addition to practices continuing to bill traditional Medicare fee-for-service claims, including reimbursement for Part B drugs administered during OCM episodes at ASP plus a 4% to 6% margin.

While some of the OCM rules and specifications will remain vague pending the official start, here are five over-arching trends we can begin to consider now:

  1. The program is designed to impact cancer care nationwide.. Whether your practice applied or not, your hospital may be impacted. Participating practices will engage in practice transformation and this will be a valuable learning opportunity for cancer programs everywhere. OCM is a multi-payer model and many national payers applied. The practice of oncology is shifting quickly to value-based payment models, and just as early-adopters of medical homes will more easily qualify for OCM, early-adopters of OCM will be better poised to meet the next wave of value-based payment requirements.
  1. Coordination of integrated care teams will be crucial. One of the core tenets of OCM is the creation and use of a comprehensive care plan and as part of the care plan, an integrated care team will be designated. This is how responsibility for each aspect of the patient’s care will be made explicitly clear (e.g., the cancer care team, the primary care/geriatrics care team, etc.). As this type of cross-functional integration becomes the norm, conversations between providers and payers will revolve increasingly around care coordination and management fees.
  1. Data sharing is a must. Another core tenet of OCM is the use of data for continuous improvement in patient care management and quality. OCM data sources will include practice-reported data, patient-reported data and Medicare claims data. Even before the program begins, you can expect the collection and distribution of baseline data on designated measures to inform initial evaluations. While CMMI will provide data feedback reports, practices that push for broader interoperability of their health IT solutions will be best positioned for success in the OCM landscape. Practices can do this now by asking their current EMR vendors to provide the necessary interfaces to make all of the practice’s IT systems interoperable, and by taking steps in future IT contracting processes to protect themselves from potential information blocking by ensuring they have the necessary interfaces specified in their contracts. The goal is to use the wealth of data that is amassing now to better understand medical practice at the national scale, improve outcomes, realize risk-stratified care delivery, and meet the requirements of alternative payment models. To achieve this, practices will need all of their IT vendors (not just their EMR) to support data interoperability.
  1. Patient-reported outcomes (PROs) will be mission-critical. The use of PROs in care delivery is on the rise. This is because data shows that people who are engaged and involved in their own healthcare feel more than just greater satisfaction with their experience; they actually realize better outcomes. Only through the productive PROs that come from effective patient engagement will providers be able to deliver the proactive quality of cost-efficient care that OCM is all about. When patients are motivated to communicate their symptoms or side effects early on, providers can intervene before things escalate into emergency situations. This is why there is an increased focus on the use of patient engagement tools and quality performance reporting in the Merit-based Incentive Payment System (MIPS) which, like OCM, will also shape how physicians are paid in healthcare’s value-based future.
  1. New technology solutions are needed. To most cancer programs, more than a few OCM quality measures will be completely novel. Only through the right combination of people, processes and new technical capabilities will programs be able to transform clinic workflow to meet and report on these new quality measures. For example, beyond attesting to Meaningful Use Stage 1 by the end of the first model performance year, OCM practices will need to support the electronic availability of patient-centered, integrated care plans. Also needed are user-friendly tools for collecting and reporting PROs, for assessing satisfaction and psychosocial distress, and for connecting patients with local support services as appropriate. New health information technology will be required beyond the standard clinical EHR systems, and the ability for these systems to readily interoperate with the EMR will be mandatory.

Putting these features in place now won’t just set practices up for success in advance of the inflection point in cancer care delivery that OCM will bring; they will improve experiences, and outcomes, for cancer patients. And that, ultimately, is the point.

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