The Center for Medicare & Medicaid Innovation first introduced its Oncology Care Model (OCM) last year. OCM went into effect July 1, 2016, and will run through June 30, 2021. The new multi-payer model is the first CMS physician-led care model aimed at improving cancer treatment for Medicare beneficiaries. CMS hopes to see improvements in care coordination and access, as well as a decrease in unnecessary services and Medicare expenditures.  OCM may be an important experiment for Medicare’s initiatives to implement alternative payment models for specialists, but will the rewards be enough to move the dial away from entrenched payment arrangements that reward volume?

Episode of Care Agreement

OCM participants agree to financial and performance accountability for six-month episodes of care.   Participants can enter into new episodes of care if the previous episode ends and the beneficiary still requires care. An episode of care includes all Medicare Part A and Part B services, as well as some Part D costs. Treatments and services prior to the triggering chemotherapy session are not included in the episode.

Participant Expectations

196 physician practices and 17 payers were selected by CMS to participate in this five-year model. Participating practices must use EHR systems and commit to data-driven continuous quality improvement. In a June 29, 2016 press release, CMS reported all practices are also required to provide enhanced services, including:

  • Patient navigation;
  • A care plan in line with the Institute of Medicine’s Care Management Plan report;
  • 24/7 access for patients to an appropriate clinician with access to patient medical records; and
  • Therapeutic treatments consistent with nationally recognized clinical guidelines.

Non-Medicaid payers are expected to provide payments for enhanced services, focus models around patients receiving chemotherapy, engage in data exchange with other participants, and align with OCM core quality measures.

A full list of participants is available at the CMS Oncology Care Model website.

Quality Measures

OCM selected quality measures across four National Quality Strategy Domains: Communication and Care Coordination, Person and Caregiver-Centered Experience and outcomes, Clinical Quality of Care, and Patient Safety. Clinical improvements will be measured against clinical data and CMS will play an active role throughout the five years to provide feedback and facilitate the exchange of data, successes, and lessons learned.

Additional Payments

Participants will receive Monthly Enhanced Oncology Services Payments of $160 per-beneficiary in addition to their regular Medicare fee-for-service payments. As an incentive to improve care for beneficiaries and lower the cost of care, OCM will also retrospectively calculate Performance-Based Payments based on practice achievements and reductions in expenditures.