Blog

By Marcus Neubauer, MD   |   July 2018

Since July of 2016, roughly 187 oncology practices across the country have been participating in the Oncology Care Model (OCM), the Center for Medicare & Medicaid Innovation’s (CMMI) new program designed to reduce the cost of care while improving quality and patient outcomes. Sixteen practices in The US Oncology Network (The Network) are participating in this care delivery/payment model, providing enhanced care to thousands of Medicare patients.

The Oncology Care Model is a very complex program, and there is a definite learning curve for practices trying to implement it. From input gathered so far across The Network, as well as from my own experience with the OCM, there are some critical activities that must be performed well to ensure success with the program.

Key Activities when Participating in the OCM

Initially, practices must determine which patients are qualified for the program. Identifying patients is challenging, especially those patients who are only on oral drugs, and workflow changes within the practice must be implemented to pinpoint eligible patients. Once patients are enrolled, practices must then bill for the monthly-enhanced oncology services (MEOS) CMS pays to fund the program. New processes and procedures will be needed to ensure all MEOS payments are billed and collected to support the special services being provided.

MEOS payments must be utilized to fund the enhanced care practices are required to deliver according to terms of the program, rather than being used for other purposes. Medicare refers to this as appropriate cost resource utilization. Data must be submitted to verify how the money is being spent, including information about new hires that are critical to the OCM, as well current employees who are spending time on the program.

Performing well on all quality metrics and reporting the data are key activities of the OCM. Practices must report their performance data through the OCM portal, submitting detailed information about each enrolled patient. Practice performance is also judged on quality measures drawn from CMS claims data. The quality measure relating to the practice’s ability to keep patients out of the hospital is critically important, and practices must excel on this metric to succeed with the program.

Practices must also pass inspections by CMS and be prepared for close-up scrutiny. The agency may conduct on-site visits and detailed audits to ensure program rules are being followed. Many of the OCM requirements are designed to drive and support optimal outcomes, so it is critical for the practice to adhere to terms of the program. Practices that do not meet all requirements may be removed from the OCM, even if they are performing well in other areas.

Appropriately managing and reducing the cost of care is undoubtedly the most crucial activity that must be done well, as controlling costs is a major goal. The program is under close observation by CMS and CMMI to evaluate whether or not the model design can drive better care and outcomes at a reduced cost. Practices that have high performance scores in other metrics but report exorbitant costs will not succeed.

Activities help practices transition to value-based care

Excelling in these key activities can help ensure success in the OCM, while also providing a strong foundation for value-based care, overall. While the OCM is a five-year pilot project ending in 2021, value-based cancer care is not going away. The government is focused on driving value in healthcare, so programs like the OCM will only become more commonplace. To thrive in this new environment, practices must adapt by transforming their organizations to meet the needs of this new way of delivering care.