The first 12 months of the Center for Medicare and Medicaid Innovation’s Oncology Care Model (OCM) has been a significant learning experience for participants.
Practices have had to come to grips with how different OCM is from other bundled payment models like the Comprehensive Care for Joint Replacement (CJR) or Bundled Payments for Care Improvement (BPCI) programs, which have clear-cut provider attribution and target prices at the time of episode initiation. OCM is a unique animal, demanding a sharp understanding of the program―however, many of its quirks have only fully emerged over the course of the past year. Here are the top five lessons learned for participants:
1. It’s critical to grasp OCM’s nontraditional bundle framework: Oncology patients are likely to receive several opinions upon diagnosis or advancement of disease and thus receive care at multiple practices throughout an episode of care, so it can be unclear how to identify which practice was ultimately most responsible for the patient’s care and should “own” the episode. CMS’ solution to this challenge is an attribution method based on visit frequency, but this can raise some major challenges. Many practices find that they are unsure of which patients’ episodes they will ultimately own. In a performance period, a practice may see 600 Medicare beneficiaries for oncology services, but only a fraction of those will actually be attributed to them at the end of the episode—a consequence of the retrospective practice assignment that’s emerging as analysts review the claims data covering the first performance period.
2. Strategies are needed that are different from those in other bundled payment programs: Participants in programs like CJR know there are a few things to target to ensure effective treatment across an episode: readmissions, post-acute care and preferring home health instead of nursing homes for low-acuity patients. Those methodologies do not necessarily work when it comes to OCM. Nearly half the cost for the ten cancer types with the largest episode volume is for the chemotherapy drug alone—a cost that a practice is not likely to be able to change. There are several alternative cost drivers OCM practices should consider, including:
- inpatient admissions, such as those that may be unplanned or unrelated to cancer care;
- emergency department utilization;
- ancillary services, such as lab and imaging costs;
- supportive cancer therapy drugs, such as bone density supports, antiemetics, and others that can contribute to the cost of care; and
- the cost of utilization of services at the end of life.
3. CMS has defined target prices for bundles in a unique way: Unlike other programs, the OCM target is not based on the practice’s historical average of episode expenditures. This has confused some practices—many of which only realized that fact six months into the program.
Instead of basing those payments on an individual practice’s historic data, CMS designed a national predictive model based on three years of episodes. This was to assess factors that affect price, understand which of those factors have the greatest influence on cost, and then create a target price methodology.
This model has been challenged by some participants who expected to see stronger predictability of actual episode expenditures within individual cancer types. But, there are reasons why that isn’t possible in the program at this point in time. It is primarily a result of the fact that the national model was built solely from Medicare’s administrative claims database—and the claims data lack important clinical information about the cancer-like stage or molecular mutations, which my team believes should be incorporated into the methodology for setting target prices in the future.
4. Achieving a performance-based payment requires investment: The first step is to have a net episode expenditure amount below the overall target amount. CMS may then issue a payment for savings if the practice is reporting to the OCM data registry, has achieved a minimum quality performance threshold and has implemented all required practice redesign activities. In particular, the practice redesign activities are fairly involved, requiring commitment by leadership, strategic implementation and an investment of resources. These activities include:
- certified electronic health record (EHR) technology;
- 24/7 clinician availability with real-time access to patient medical records;
- use data to drive continuous quality improvement;
- therapies compliant with nationally-recognized clinical guidelines;
- patient navigation; and
- individualized care plans.
5. Reconciliation takes a long time: There are nine performance periods that will be part of the program. But, in any of those performance periods, participants will not receive their reconciliation results until nearly two years after the actual episode was initiated. This matters because to continue taking one-sided risk, practices have to achieve a performance-based payment by the fourth performance period, ending in 2018.
If they don’t achieve a performance-based payment by the end of 2018, practices will either have to take two-sided risk or leave the program entirely. Many practices are concerned that they will not have enough time to impact the cost curve with well-informed interventions and program evaluation between the time they learn the outcome of their first performance period and the time they will need to decide whether to stay in the program.
The OCM program is fundamentally different from other bundled payment models and brings its own challenges. However, the scope of cancer treatment is also fundamentally different from other types of care, so a different approach may not be a bad thing.
While success in the program is no small feat, understanding how to achieve that success and taking advantage of every opportunity to meet the requirements—while continuing to put patients first—can lead to better care and outcomes.
About the Author
Alyssa Dahl is a Principal Healthcare Informatics Analyst at DataGen, where she conducts research and develops analyses around emerging payment models, comparative efficiency, and care patterns. A healthcare data analytics and policy firm, DataGen illustrates the financial implications of payment policy changes to healthcare organizations across the country. Alyssa has a Master of Public Health degree in Epidemiology from the State University of New York at Albany where she is also currently a PhD candidate.
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.