The Challenges With OCM
In beginning to understand the potential of OCF, it is important to review the challenges the oncology world feels with OCM. At a high level, OCM, which began in July of 2016, is a CMS payment model targeting oncology practices in an effort to better serve Medicare beneficiaries. The model was scheduled to end in June of 2021; however, with the recent global pandemic, CMS has extended OCM until June of 2022.2
By participating in the model, oncology practices strive to improve quality of care for their patients, as well as provide enhanced oncology services (also outlined by CMS). Payments within OCM provide practices with a monthly payment designed to cover the expenses of the mandated oncology care practice patterns, as well as a performance-based payment aimed to incentivize improving quality while reducing costs across cancer episodes.3
While the foundations of the model align with the overall oncology community’s commitment to value-based care, there are a few pieces of the model that received feedback across the past years.
There are initial costs and burdens in building practice group infrastructure for OCM.
Across participants, many practice groups have mentioned the costs they incurred to train up their staff on the new model and develop the internal infrastructure to coordinate care. Like many new things that require investment, this is not unheard of. Yet, in reviewing the model, practices also frequently note extensive reporting criteria for model participants, particularly around the labor of aggregating quality metrics from multiple sources and places.4
OCM’s payment structure does not reflect the current state of novel treatment prices.
Since OCM was introduced in 2016, it’s payment structure is founded on claims data before 2015. With the vast changes to oncology treatments between 2015 and 2020, many practices feel the pricing structure of the model does not accurately take into account the pricing treatment offerings that have been introduced more recently. As a result, some practices feel there is a penalty for using more current treatments that are sometimes more expensive.5
Many practices struggle with the attribution of patients.
For many of the CMS payment models, the number of attributed patients is a key factor. In OCM, oncology practices have expressed a variety of challenges around attribution. For example, to identify the number of attributed patients, practices can look to see which patients have received chemotherapy. However, this is much more complicated for patients who are receiving oral chemotherapy. Additionally, many practices hope for reform to the monthly payment attribution process.6
With this feedback in mind, CMS introduced the new model, OCF, colloquially referred to as OCM 2.0.
How does the Oncology Care Model work?
Oncology Care First (OCF), similar to the CMS’ OCM, is another model intending to promote coordinated, holistic oncology care for patients while reducing overall costs. The model is available to physician group practices or hospital outpatient departments.
Similar to OCM, to participate in the model, practices must7:
- “Offer beneficiaries 24/7 access to a clinician with real-time access to their medical records;
- Provide the core functions of patient navigation;
- Document a care plan for beneficiaries that contains the 13 components of the Institute of Medicine’s (IOM) Care Management Plan;
- Treat beneficiaries with therapies consistent with nationally recognized clinical guidelines;
- Use Certified Electronic Health Record Technology (CEHRT) as specified in regulation;
- Utilize data for continuous quality improvement; and
- Gradually implement electronic patient-reported outcomes (ePROs).”
The OCF model combines both upside and downside risk for it’s oncology practice groups and offers 3 risk tracks: (i) upside risk, (ii) downside risk, (iii) blending of other two risk tracks. For any practices transitioning from the sunsetting OCM model to OCF, there is a requirement to take on downside risk to participate. Other practices dipping their toe into the water of value-based oncology are eligible for a one sided risk track for a defined period of time as they grow accustomed to the model.
In terms of the payments, OCF provides two types of payments for members.
- The first is the Monthly Population Payment (MPP). This is a fixed capitated payment that provides OCF practices a set sum for E&M services rendered by a medical oncologist. This sum is calculated based on the practice’s full Medicare population and includes patients who are treated with chemotherapy and those that are not.
- The second is the Performance Based Payment (PBP). This payment mirrors the performance payments in OCM. The payment holds OCM practices responsible for the total cost of care (including drugs) across a patient’s six-month episodes. With this payment, if practices see total costs of care below the benchmark (both from a cost and quality perspective), then they receive the PBP. On the other hand, if practices exceed the benchmark, then they owe CMS a PBP recoupment. For the PBP, an episode is triggered by chemotherapy and only applicable for beneficiaries enrolled in Part B or Part D Medicare fee-for-service.7