Bringing the Oncology Care Model into Focus Patient and Provider Access

Leah Ralph
Director of Health Policy, ACCC

On February 12, the US Department of Health & Human Services announced its much-anticipated Oncology Care Model, developed by the Centers for Medicare & Medicaid (CMS) Innovation Center as part of the broader effort to lower healthcare costs and tie reimbursement to quality and value. The Association of Community Cancer Centers has been conducting an in-depth analysis, and the model generally looks similar to the discussion draft made available in August last year; although the model contains many positive elements, many questions still remain.

At its core, the Oncology Care Model looks similar to a patient-­centered oncology medical home or accountable care organization, with a target expenditure and shared savings component that encompasses the total cost of patient care during a particular period of treatment. The model is a voluntary, 5-year program slated to begin in spring 2016. Physician group practices, hospital-based practices (except for prospective payment system–exempt hospitals), and solo practitioners who furnish cancer chemotherapy are eligible to participate.

Payments will be based on a 6-month episode of chemotherapy treatment that is triggered by the administration of a preset list of chemotherapy drugs, and will take into account all Part A and Part B, and some Part D expenditures for that patient during the episode. In addition to a fee-for-service payment, providers will receive a care coordination payment to improve quality of care ($160 per patient, per month during the episode) and, to incentivize lower costs, a performance-based payment that will be based on the difference between a risk-adjusted target price and actual expenditures during the episode. The payment arrangement is 1-sided risk, with the option of converting to a 2-sided risk in the third year.

Importantly, the care model is a multipayer model in which commercial payers and state Medicaid agencies are encouraged to participate. Aligning financial incentives by engaging multiple payers will leverage the opportunity to transform oncology care across a broader population. During its process of selecting practices to participate, CMS will favor those that participate with other payers in addition to Medicare. Practices will also have to meet certain quality metrics and undergo practice transformation requirements, including effective use of electronic health records, providing 24-hour access to practitioners who can consult the patient’s medical record in real time, developing comprehensive patient care plans, offering patient navigation services, and targeting continuous quality improvement.

Although we were pleased to see much of the Association of Community Cancer Centers’ feedback incorporated into the final version of this model—and we appreciated the opportunity to provide meaningful input before the model was finalized—our dialogue with CMS is ongoing. Our members continue to have questions about the benchmarking methodology, specifics on the quality metrics and practice transformation requirements, eligibility to participate in the model, and more. We continue to work with CMS to secure answers to these questions.

If your practice is interested in participating, or considering participation, we encourage you to submit a nonbinding letter of intent to CMS by the deadline of May 7, 2015. We anticipate that CMS will continue to provide additional guidance until the final application deadline of June 18, 2015.

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