Oncology Care First: What Providers Need to Know About CMS’ Proposed Model for Value-Based Cancer Care

November 8, 2019

-By Dr. Andrew Hertler, Rani Khetarpal and Ashley Ridlon

The CMS Innovation Center has proposed a new five-year voluntary value-based oncology model called Oncology Care First (OCF). Replacing the Oncology Care Model (OCM), OCF would kick off in January 2021 and include several key changes designed to increase risk, cash flow and predictability for practices, while reducing administrative burden. Those changes were highlighted in a Nov. 4 listening session that CMS held with stakeholders:

  1. A stronger push toward two-sided risk, with CMS considering requiring all current OCM participants to enter two-sided risk in year one and otherwise limiting time for new practices in an upside-only track before moving to one of the two higher-risk tracks. This is consistent with the agency's goal of having 100% of Medicare payments in two-sided risk arrangements by 2025.
  2. Prospective payments intended to cover total cost of care for Medicare fee-for-service (FFS) cancer patients, as opposed to the $160 per patient flat fee in OCM to cover only "enhanced oncology services." The payment includes a Management Component (Enhanced Services, E&Ms) and an Administration Component (drug administration services, E&M payments to hospital outpatient departments, or HOPDs, where applicable). These Monthly Population Payments (MPPs) will vary and be reconciled based on risk tiers, as well as national cost trends and participant-specific factors. CMS has proposed that any HOPD that provides chemotherapy services for 25%  or more of an oncology practice participant's attributed episodes would need to voluntarily participate in the model in a grouping with the practice, in order for the practice  to be eligible for the model. Like OCM, the model also includes Performance-Based Payment (PBP) component, which reconciles total episode expenditures against a benchmark or target amount.
  3. A more broadly defined set of assigned beneficiaries. Aside from patients in active chemotherapy treatment, beneficiaries would include those with a cancer-related diagnosis who are on hormonal therapy, are under surveillance, or are receiving ongoing care management services. In one change that is expected to reduce provider burden compared to OCM, participants will not be required to submit claims for the prospective MPP payment, as beneficiary assignment is tied to receipt of evaluation and management (E&M) services with cancer diagnosis. PBP calculations and episode initiation will be based on a more narrowly defined subset of cancer patients undergoing chemotherapy. Participating practices would need to provide only 25% of that patient's E&M services (rather than a "plurality" as in OCM) at minimum to keep them attributed. 
  4. Tweaks to the benchmark and episode target pricing methodologies intended to improve their accuracy. Specifically, CMS is considering applying trend factors separately for each cancer type in the benchmark calculation and adjusting for novel therapies at the cancer type level rather than the participant level, as is done in OCM. Otherwise, CMS proposes to use roughly the same complex episode pricing methodology used in OCM.  
  5. A proposal to gradually add electronic patient reported outcomes (ePROs) to the list of care redesign requirements for practices. ePROs would be intended to monitor patient symptoms and identify high-risk patients for complications or utilization of emergency services. OCF would include six other care redesign activities that are currently featured in OCM, though some stakeholders have called for more flexibility for care delivery innovation.
  6. Improvements to ease administrative and financial burdens. Fortunately, CMS has also committed to reducing the number of data collection elements required of practices, to getting more timely data to practices (on a monthly basis) and to cutting six months off the financial reconciliation lag time, all of which would significantly improve participants' ability to evaluate progress and continuously improve in the model. As in OCM, CMS will encourage private payers to participate by aligning their payment and delivery strategies with Oncology Care First. 

CMS proposes a January 1, 2021 start date to ensure there is no gap between the last OCM episodes initiated in 2020 and the start of the new model.

The deadline for written comments on the proposed model has been extended to Dec. 13. New Century Health has requested that CMS also allow stakeholders an opportunity to review the episode pricing methodology in detail for feedback before it is finalized. We will continue to assess how well the model accounts for variation between and within cancer types, including cancer subtype and disease progression, and will recommend ways to optimize pricing, payment and risk for greater predictability and sustainability of the model over time. 

We are encouraged at the continued investment by CMS in the future of value-based oncology care. There is tremendous opportunity to improve care for patients while lowering costs, and we look forward to continuing to partner with oncology practices to succeed in this and other models in the future.

About the Authors

  • Dr. Andrew Hertler is Chief Medical Officer of New Century Health (NCH). He responsible for the advancement of the company's clinical quality and value-based strategy, utilization management policies and clinical thought leadership initiatives.
  • Rani Khetarpal is Vice President of Value-Based Provider Partnerships for NCH. She leads the development and strategy of the company's provider-based risk partnership, which works with providers to be successful in oncology value-based care models.
  • Ashley Ridlon is Vice President of Health Policy for Evolent Health, the parent company of NCH. She leads the development and implementation of the company's health policy and advocacy strategy to drive value-based health care transformation across the country.

 

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