The Oncology Care Model (OCM) was launched in July 2016 to further delivery of higher quality, more coordinated cancer care at a lower cost to Medicaid. In return for delivering enhanced services such as care management and coordination, and generate sustainable cost savings, OCM participants, representing nearly one-third of community-based oncology practices across the US, would receive a payment of $160 per beneficiary per month for the duration of a qualifying 6-month chemotherapy period, plus the opportunity to earn a share of savings if they exceed a target price threshold.
As part of the OCM program, the Centers for Medicare and Medicaid Innovation (CMS Innovation Center) tracks each practice’s performance during the 6-month periods – so-called “performance periods” – then shares data back with practices about one year later.
In late-February, the CMS Innovation Center released Performance Period 3 (PP3) results, which measured the performance period with episodes starting July 2, 2017 to Jan. 1, 2018. Much like prior performance periods, the focus of the reporting was to provide utilization and quality performance details, trend and novel drug therapy adjustment results and average actual episode costs compared to target or expected episode costs for participating OCM Practices. Additionally, CMMI reconciled Performance Based Payment (PBP) achievements from Performance Period 1 (PP1) and Performance Period 2 (PP2) while truing up Monthly-Enhanced Oncology Services (MEOS) payments – recouping overages as deemed appropriate.
Now well into its third year, the Oncology Care Model is coming up on its next major inflection point. By the end of August 2019, practices will have received their Performance Period 4 (PP4) results. Those that have not generated a performance-based payment through PP4 initial reconciliation will face a decision to take two-sided risk or leave the program. While quality and cost performance results across OCM practices continue to improve, only 33 percent of practices have earned a performance-based payment so far, underscoring the implications of this quickly approaching milestone.
OCM participants have nearly closed the gap between actual and target costs per episode
Practices have closed the cost gap on average, down to about a two-hundred-dollar cost delta per episode, demonstrating that they are learning what it takes to meet CMS Target Prices. Over the course of the past three years, these practices have operationally transformed to deliver the highest quality care while generating cost efficiencies.
What were some of the most notable transformations?
- Practices have begun reconsidering aggressive therapy in advanced stages of illness with no curative options and have increase referrals to palliative care. For one OCM practice, increasing referrals to palliative care resulted in a 17 percent reduction in total costs of care for patients in the final 30 days of life.
- Preeminent OCM participants are augmenting care management services with risk prediction models, enabling their care teams to proactively identify those patients are highest risk of an emergency room or hospital admission and intervene when necessary, reducing complications requiring hospitalization. One leading practice achieved impressive results in PP3, including a reduction of inpatient admissions by 19 percent compared to baseline performance.
- CMS Target price per episode is risk-adjusted based on patient co-morbidities. Most oncologists under code co-morbidities and hence fail to have their target price full risk-adjusted. Many leading practices have begun taking steps to close co-morbidity documentation gaps, which not only helps fully risk-adjust patients but also highlights opportunities to actively manage co-morbidity conditions. In one case, by proactively referring cancer patients with cardiac-related co-morbidities to a cardiologist, the practice reduced total cost of care for these patients by 19 percent.
- Practices also discovered that comprehensive documentation helped to ensure the OCM Target Prices, which apply historical data to the patient’s current clinical status to predict his or her cost of care, accurately reflected each patient’s holistic clinical record, amounting to as much as a $4,800 increase in Target Price per documented comorbidity.
- Because drugs are now the single largest driver of episode costs, many practices are starting to look at lower cost alternative therapies, such as generics and biosimilars, where efficacy and patient safety are the same, to drive sustainable cost savings.
While performance overall for the OCM program is trending up, there still remains significant variation across practices as well as within a single practice across performance periods. What does this mean for OCM participants? Practices who received a performance-based payment in one period should not expect to get one the following period without continuing to demonstrate tangible performance improvement. Practices should also expect to see ups and downs in their performance period-over-period, especially those with a small number of episodes in any given performance period.
Monthly Enhanced Oncology Services recoupments continue to rise as practices struggle to accurately identify eligible beneficiaries
On average, practices are spending 20 percent of their overall effort just identifying OCM episodes. This expenditure of time, money and staff resources could be otherwise spent delivering more enhanced services and care coordination. While technology-based solutions can improve accuracy of episode identification to as much as 85 percent, to further close the gap, practices may need to augment their technology with human curation to double-check unknown data points, such as calling patients to confirm oral prescriptions have been filled. Some leading practices have already begun incorporating these efforts into their overarching care coordination strategy.
To support the long-term success of the value-based reimbursement models in oncology, it will be paramount for CMS to define an episode in terms that can be definitively identified at the time an episode starts rather than waiting for attribution reporting. Moreover, OCM practices will need to ensure more timely access to data, providing visibility into each patient’s complete claims experience. This will enable efficient, timely enhanced oncology services from day one of the episode.
Next Steps for OCM Practices
Practices’ homework this summer, especially for those who have yet to receive a performance-based payment, will be to determine their appetite for taking on two-sided risk, evaluate what strategies they could take on, and estimate the impact of these efforts. New tactics may include enhancing existing care coordination efforts, investing in technology-enabled prediction models to identify high-risk and high-cost patients, or even putting in place a stop-loss insurance program. Most importantly, this assessment should be informed by a sensitivity analysis around best- and worst-case scenarios before making the decision to remain in or depart from the program.