Policy & Regulation News

CMS Selects 200 Groups for Value-Based Care Oncology Model

CMS has chosen 200 physician groups and 17 health insurers to participate in a value-based care reimbursement model focused on oncology care.

By Jacqueline LaPointe

- The Centers for Medicare and Medicaid Services (CMS) has announced that almost 200 physician groups and 17 health insurance companies will join the Oncology Care Model, a value-based care program starting in July for providers who furnish chemotherapy services to cancer patients.

CMS chooses participants for value-based care oncology model

The participants in the five-year care delivery program range from solo oncologists to large practices with hundreds of physicians and covering urban, suburban, and rural areas. With more than 3,200 oncologists now included in the program, CMS aims for the Oncology Care Model to promote higher quality cancer care and lower healthcare costs for approximately 155,000 Medicare beneficiaries served by participating providers.

“OCM [Oncology Care Model] aims to promote whole practice transformation through the use of aligned financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for fee-for service (FFS) Medicare beneficiaries undergoing chemotherapy,” explained the fact sheet.

“The model intends to improve health outcomes and produce higher quality care at the same or lower cost to Medicare.”

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  • Practices in the Oncology Care Model will face a two-part payment approach for administering chemotherapy to Medicare beneficiaries and the six-month episode following the treatment. Each participant will receive a monthly Enhanced Oncology Services Payment as well as performance-based payments for episodes of care.

    The monthly Enhanced Oncology Services Payment of $160 per beneficiary is designed to provide practices with the financial resources to facilitate quality care. 

    Participants will also be able to earn performance-based payments for achieving high marks on quality measures and holding Medicare spending below certain benchmarks.   The quality measures span four of the National Quality Strategy Domains, including Communication and Care Coordination, Person and Caregiver-Centered Experience and Outcomes, Clinical Quality of Care, and Patient Safety.

    Twelve of these quality measures will be used to calculate the performance-based payments, stated the fact sheet.

    In addition to specific quality measure and Medicare spending goals, participating practices must also provide enhanced services, such as continuous patient access to an appropriate clinician who can view medical records, treatments with therapies that align with nationally recognized clinical guidelines, core functions of patient navigation, and care plans that encompass the components in the Institute of Medicine Care Management Plan’s report on high-quality cancer care.

    The practice must also employ data-driven methods to implement quality improvements and use certified EHR technology to qualify for payments under the model.

    The Oncology Care Model covers almost all types of cancer and the episodes of care start on the date of the initial Medicare Part B or Part D chemotherapy claims. Qualifying episodes of care also include all Medicare Part A and Part B services that beneficiaries receive during the period and specific Part D expenditures. These episodes last for six months after initiation and beneficiaries who continue chemotherapy after six months will begin a new episode.

    CMS also explained that the model is a multi-payer system that includes commercial payers as well as Medicare. All participating payers will align their payment models with the program’s reimbursement structure by paying for enhanced services and performance, centering their models on patients receiving chemotherapy, sharing data with other participants, and aligning quality measure sets.

    “Although there are differences between OCM-FFS and other payers in certain areas, such as specific payment amounts and episode definition, the approach to practice transformation is consistent across all payers in OCM,” the fact sheet stated.

    Overall, the Oncology Care Model was designed to promote value-based care by incentivizing providers to improve cancer care quality and lower healthcare costs through financial rewards for improvements. CMS also intends for the model to advance value-based reimbursement arrangements across public and private payers.

    While the new model is set to launch next month, CMS has already included it as a qualifying APM under MACRA’s Quality Payment Program.

    Depending on the final MACRA ruling, eligible clinicians who participate in the Oncology Care Model could earn a five percent reimbursement bonus on Medicare Part B services and receive higher annual increases in their payments. Participants would also be exempt from reporting to the Merit-Based Incentive Payment System (MIPS) under MACRA.

    Dig Deeper:

    Risk-Based Alternative Payment Models Key to Value-Based Care

    Why the Value-Based Care Journey Begins with Assessment