On November 1, 2019, the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (Innovation Center) released a Request for Information (RFI) on the Oncology Care First (OCF) model. The Innovation Center posted the RFI in anticipation of a public listening session, held on November 4, 2019, to gather stakeholder feedback on the potential model. In this post, Foley summarizes important features of the model, analyzes the differences between OCF and the current Oncology Care Model (OCM), and summarizes key takeaways from the listening session.
According to the Innovation Center, the OCF model aims to improve health outcomes and increase the quality of care for Medicare beneficiaries. Further, OCF aims to provide participants in the model with financial incentives to eliminate volume-driven revenue cycle management without diminishing accountability for health outcomes.
The OCF model expands on the successes of the OCM and would be a voluntary, five-year model starting January 2021, when OCM is set to expire.
The OCF model incorporates two payment mechanisms.
OCF participants (providers) would receive a prospective monthly population payment (MPP) for evaluation and management (E&M) and drug administration services. In the RFI, the Innovation Center proposes calculating the MPP based on “historical payments trended forward . . . applied to volume and case mix in the most recently available population data.” The MPP will consider those beneficiaries with a cancer or cancer-related diagnosis who have received an E&M service.
The Innovation Center proposes including E&M and drug administration services in the MPP because these are the primary services provided by oncology offices. However, the Innovation Center is also considering including imaging and laboratory services, as well. Additionally, under the proposal, there would be a separate MPP for the provision of “enhanced services.” These services include the four from the OCM, and a new fifth as follows:
Finally, the MPP would take into account different spending patterns based on risk. Specifically, the Innovation Center would calculate a separate MPP for three different risk stratum:
In addition to the MPP payment, OCF participants would have the opportunity to receive a Performance-Based Payment (PBP) by reducing expenditures below an episode benchmark amount for six-month episodes of care. The Innovation Center would consider those Medicare beneficiaries who receive chemotherapy under Medicare Parts B or D for a cancer diagnosis of any stage when calculating the PBP. Alternatively, however, OCF participants may owe CMS a repayment if they do not reduce episode expenditures during an episode of care.
The PBP episode benchmark would be calculated based on historical Medicare payments during the baseline period. Additionally, OCF participants’ PBP may be greater if they meet the quality measures currently used in the OCM Quality Measure Set. Participants with better performance based on the OCM quality measures would receive higher PBPs or, alternatively, owe CMS less in recoupment.
Like the MPP, the PBP takes into account risk. The Innovation Center proposes three risk tracks:
The Innovation Center defines risk based on the participant’s episode benchmark amount.
The Innovation Center aims to build off the successes of OCM. However, OCF does differ from OCM in a few notable ways.
Like OCM, the OCF would be a multi-payer model, with commercial payers and state Medicaid agencies partnering with the Innovation Center to align their payment models with OCF. The Innovation Center hopes that multi-payer alignment would reduce costs, improve the quality of care, allow whole practice transformation, and remove any burdens to innovation.
The majority of stakeholders active during the listening session represented provider groups currently participating in OCM or professional associations. There were several aspects of the proposed OCF model that stakeholders were especially eager to discuss at the listening session.
In conclusion, OCF reflects the Innovation Center’s continued shift away from FFS towards value-based payment programs. While the RFI was informal in nature, some speculate that a proposed rule may already be in the works. The RFI was long awaited, and while it gives insight into the next steps, it leaves a number of questions that will need to be answered. Interested parties are encouraged to submit their feedback on the RFI by Friday, December 13, 2019 to OCF@cms.hhs.gov.
Join us for a deeper discussion of the Oncology Care First Model during the Association of Community Cancer Centers & Cancer Center Business Summit taking place from March 4-6, 2020 in Washington, DC. Learn more and register for the program here.