A New Care Model on the Horizon

Dawn Holcombe, MBA, FACMPE, ACHE

March 2015, Vol 5, No 2 - From the Editor


Our inboxes are overflowing with news of the Oncology Care Model (OCM) that was announced by the US Department of Health & Human Services on February 12. Full details are being unveiled regarding this bundled payment model, which was developed by the Centers for Medicare & Medicaid Services (CMS) Innovation Center, and practices are starting to assess the expectations of the program versus the risks and rewards of participation or a decision not to participate.

According to available program details, participating providers will receive a per-beneficiary, per-month (PBPM) care management payment of $160 for 6 months for each beneficiary receiving chemotherapy, hinged on the initiation of treatment; they will also be eligible to receive performance-based payments. Participating providers are expected to be available and have access to patient medical records on a 24-hour basis to manage common therapy complications in the hopes of avoiding hospitalizations or emergency department visits.

Another important element of this program calls for CMS to consider support and participation from other payers. Payers are encouraged to submit letters of intent to participate earlier than practices so that practices may review potential partnerships in their markets. The scoring and evaluation process that CMS will use to accept final participants is weighted heavily toward participants who are partnering with other payers in this program.

It will be important for practices considering participation to read the fine print surrounding this model. The application is quite detailed and requires projection of volume, a listing of beneficiaries, and attestation of ability to perform on specified measures. Practices will have to create and submit a full implementation plan for the first 2 years of the program, including current and future timelines for implementation of program processes.

Electronic practice support will be critical. Practices must be compliant with stage 2 of Meaningful Use by the end of the third performance year and have electronic support for the documentation and reporting that is part and parcel of this program. Documenting a care plan for each patient that encompasses all elements of the required 13 components of the Institute of Medicine Care Management Plan and the 10 elements of the National Cancer Institute Sample Patient Navigation activities have the potential to stretch the limits of practice systems.

The OCM has been in development for years, with input from many sources, including those in the oncology community. It will be interesting to see if the model that has been unveiled will attract significant participation. Is the $160 PBPM payment sufficient to cover the costs of participation and patient care? Are the reporting and compliance expectations compatible with current or near-future capabilities of oncology practices? Submitting a letter of intent may be easy by April 9 for payers or May 7 for practices, but is the time frame of June 18, 2015, feasible for the projections and relationships expected for a full application? Will this model be the first step in standardizing oncology payer relationships? Or will it be a voluntary program that fails to attract participants?

Time will answer these questions. For now, practices should carefully review the program, application, and participation details for themselves. Are these expectations achievable? It is interesting that only physicians may participate in this model, and that much of the expected savings will likely come from hospital services and treatment regimen choices. This is more of a bottom-up approach to finding savings than the accountable care model, which often has been housed in larger institutions.

Drug costs are included in these totals, including those billed through Medicare Part A, Part B, or Part D. Much of our cancer care pharmacy costs are found in combination regimens, and many new drugs themselves layer on top of existing regimens. Moving to episode-based, total cost-of-care bundles with incentives for savings will encourage greater attention to the total costs of care, but will it lead to restricted access to new treatments and options for Medicare beneficiaries?

The devil will be in the details of this program (ie, how it is written and executed), as well as the capability of our medical system to accept these terms. It will be interesting to watch the reactions to this program unfold in the next few weeks, as practices continue their research into and understanding of this new model.