Abstract: When launched in 2016, the Oncology Care Model (OCM) represented one of the most advanced efforts yet to migrate health care delivery from fee-for-service to fee-for-value. Practices representing nearly 3000 oncologists signed on to participate. Since then, much has been written about potential strengths and weaknesses of the model. New to the discussion is a wave of data. Practices received the results of their first performance period in February 2018 and the second performance period at the end of August 2018. This has afforded them the opportunity to identify strengths and areas for improvement, both based on what the data tells them and how it changes across performance periods. This article draws on the aggregated data and experiences of a large segment of community OCM participants to highlight the primary challenges that arose once practices were confronted with the Centers for Medicare & Medicaid Service’s assessment of their performance. In addition, the article highlights high-impact interventions that oncology practices are undertaking to further improve both care quality and cost.
On August 31, 2018, the Centers for Medicare & Medicaid Services (CMS) released its second set of Oncology Care Model (OCM) performance results. This included reports covering the first 2 OCM performance periods—a revision of Performance Period 1 (PP1) results, which measured the period with episodes starting July 1, 2016 to January 1, 2017, as well as brand new results for Performance Period 2 (PP2), which covered episodes starting January 2, 2017 to July 1, 2017. 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, CMS sought to reconcile Performance Based Payment (PBP) achievement on one hand while truing up so-called Monthly-Enhanced Oncology Services (MEOS) payments on the other—recouping overages as deemed appropriate.
The PBP Reconciliation reports reflect the OCM calculation of whether the practice has earned a performance-based bonus, based on the difference between actual expenditures per qualifying 6-month episode of cancer care and a CMS target price. As participants of the OCM program, the practices are also allowed to bill MEOS claims to support the additional services being delivered to OCM beneficiaries. The MEOS Recoupment report assesses the practice’s effectiveness at identifying beneficiaries who were eligible for the OCM based on CMS guidelines. To be eligible for the enhanced payment, the patient must have a qualifying diagnosis associated with the initiation or continuation of a qualifying chemotherapy agent. CMS provides the aggregated summary and details of all MEOS payments that were billed and then paid in error for the given period. While there are a variety of reasons why recoupment may be triggered, the 2 most common were either because beneficiaries were not attributed to the OCM practice based on the plurality of evaluation and management (E&M) office visit claims during the respective performance period or because patients were deemed not to have had a qualifying cancer diagnosis and/or no active treatment therapy in proximity to the diagnosis. All CMS attribution is based on a retrospective evaluation of paid claims data.
Integra Connect works with one of the largest cohorts of OCM providers nationwide, nearly 900 of them, including some of its preeminent participants, and therefore conducts regular qualitative and quantitative analyses of aggregated practice performance. In this article, we summarize performance trends from PP1 to PP2, assess potential financial and operational concerns revealed by PP2 results and share some of the best practices adopted to support future performance objectives. While fully digesting PP2 data and its implications will likely take practices many more weeks, our high-level initial findings include the items listed in Box 1. Our analyses are based on the individual Center for Medicare & Medicaid Innovation reports provided to OCM participants within our cohort and are therefore proprietary data.
OCM Practices are Closing the Cost Gap
For OCM PP1, the PP1 True Up Reconciliation Report included adjustments to the Initial Reconciliation Report. Because oncologists participating in the OCM program are accountable for reducing total costs of care for each qualifying 6-month chemotherapy episode—across all settings and conditions—the purpose of the True Up Reconciliation is to reflect any laggard claims, primarily from hospitals, that increased either the Target Price or Actual Expenses since the initial assessment in February 2018. In the PP1 Initial Reconciliation Report, fewer practices received performance bonuses than expected based on historical performance trends, leaving most anxious to see whether the True Up Reconciliation Report results would be more or less favorable.
While a few practices reduced their average price per episode with the additional claims, the majority found that the incorporation of late-arriving claims caused their overall episode costs to go up, either reducing or eliminating the savings achieved—not to mention reversing the bonus they had been paid, as noted during the OCM PP1 First True-Up and PP2 Initial Reconciliation Overview Office Hours.1 CMS indicated that such practices therefore needed to pay back the funds they had received months ago.1 This came as an unwelcome surprise, especially since the practices had typically already invested these dollars into OCM improvement initiatives prescribed by CMS, such as care navigation or expanded office hours.
For OCM PP2, the PP2 Initial Reconciliation Report provided more of a relief. Our cohort of OCM practices experienced a preliminary average PBP Reconciliation improvement of 46% from initial PP1 to initial PP2 results. While this progress may be attributable to the implementation of practice transformation activities and related cost-efficiencies, favorable changes in model calculation as well as trend factor and novel therapy adjustments also contributed to the perceived performance improvements.