Abstract: Clearview Cancer Institute is a private, community practice participating in the Oncology Care Model (OCM), an innovative pilot project sponsored by the Centers for Medicare and Medicaid Innovation. Through implementing processes set forth by OCM practice requirements and analyzing beneficiary claims data made available through participation in the program, Clearview Cancer Institute has successfully identified eligible patients, completed required documentation points, and increased awareness and outcomes for patients related to depression screening, hospitalizations, emergency room use, and hospice use. The practice continues to refine processes for nurse navigator triage pathways and clinical pathway compliance and tracking to improve processes and patient care outcomes. A review of new programming and program modifications implemented to enhance current programming at the practice is provided. Successes and challenges during implementation of the OCM are discussed. A subsequent article will compile and analyze more comprehensive data from the program and what that data means for the future.
Acknowledgments: Thank you to the team at Clearview Cancer Institute for their dedication to patient care and outcomes, which have made this article possible.
The Oncology Care Model (OCM) is an innovative, specialty model created through the Center for Medicare and Medicaid Innovation (CMMI), a division of the Centers for Medicare & Medicaid Services (CMS). Under this model, practices and payers enter into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients. The program seeks to “provide higher quality, more highly coordinated oncology care at the same or lower cost to Medicare.”1 It aims to accomplish this through aligned financial incentives (performance-based payments [PBPs]) and by helping practices enhance their care delivery with optimized patient navigation and improved access; reduction of avoidable emergency department visits; improved advance care planning; and improved psychosocial support.2
When the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law, it made strides in transforming the current fee-for-service Medicare system into a value-based, pay-for-performance system that rewards providers for better care instead of more services. MACRA created tracks for reimbursement: one track combines parts of the Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VBM), and the Medicare Electronic Health Record incentive program, creating the Merit-Based Incentive Payment System (MIPS); the other track is the Advanced Alternative Payment Models (APMs) option.
The OCM is one of CMS’s advanced APMs that involves 2-sided risk. Participating practices will continue to be reimbursed through Medicare fee-for-service, but this is incorporated into the OCM 2-part payment approach: Monthly Enhanced Oncology Services (MEOS) and PBPs. The MEOS payment is a $160 per member, per month payment for each 6-month episode. OCM practices are allowed to bill this fee for patients meeting eligibility criteria (eg, Medicare as the primary payer paired with a qualifying cancer diagnosis and chemotherapy initiation) for which the practice provides enhanced services, as listed in Box 1. The PBP is a bonus payment that is derived based on a complex methodology, taking into account savings to the Medicare program and quality metric performance, among other factors.3 Physicians who receive a percentage of payments through OCM are then exempt from MIPS adjustments and are eligible for other incentives. Practices electing 1-sided risk in the OCM program are considered a partially qualifying advanced APM and are still required to report Advancing Care Information (ACI) to the MIPS program. All other aspects of the MIPS program (including quality, cost, and improvement activities) are fulfilled through OCM participation.4 If a practice elects 2-sided risk in the OCM program, the practice becomes an advanced APM and is no longer required to report on ACI measures. Depending on performance, the practice may become eligible for a 5% bonus on specified services.3
In order to participate, practices must meet certain requirements (Box 1), one of which includes implementation of the Institute for Medicine Care (IOM) 13-point care management plan.5,6 Oncology practices were invited to submit an application for participation that would impact Medicare beneficiaries and any private payers that intended to participate in the model alongside CMS.
Since 1985, Clearview Cancer Institute (CCI), has served hematology and oncology patients across north Alabama. CCI is a private, physician-owned, community practice with 3 full-service locations and 3 satellite clinics and is home to 14 physicians and 17 advance practice providers. At the full-service locations, CCI offers outpatient therapy, diagnostic imaging, genetic and genomic testing and counseling, lung cancer screenings, a specialty pharmacy, autologous stem cell transplant, physical therapy, and clinical trials, including phase 1 trials.
CCI became aware of the OCM program in early 2015, and there was immediate interest in applying for participation. The OCM was attractive to CCI for several reasons. The first was that CCI met the practice requirements with the exception of the 13-point IOM care management plan. Another reason included the MEOS payments to help supplement the hiring of staff, new technology implementation, and assistance with data analytics. An additional consideration was the comparison of CCI’s practice characteristics, data, and patient population to other oncology and hematology practices. This comparison information was a strong motivator for physician leadership and was one of the major complaints surrounding previous years’ participation in the PQRS. The receipt of the Quality Resource Utilization Report each year solidified the need for comparison to specialists in oncology and hematology.
This article details CCI’s experience in applying and preparing for OCM participation, including identification of care delivery areas in need of alterations or new programming, how these enhancements were achieved, and challenges encountered throughout the process. The aim of this article is to provide practice enhancement strategies through communication of CCI’s experiences and subsequent lessons learned to aid other practices on the same journey.
A subsequent article will provide an expanded discussion of these items along with comprehensive data to inform on practice success thus far.
A discussion on methods ensues on the next page