Association for Public Policy Analysis & Management

Objective: The Center for Medicare and Medicaid Innovation (CMMI) has begun testing new models of care that focus on specific diseases, patient populations, and specialty practitioners to incentivize improved care, better health, and lower costs. The Oncology Care Model (OCM) became the first active CMMI specialty care model in July 2016. It focuses on improving health outcomes and costs for fee for service (FFS) Medicare beneficiaries undergoing chemotherapy.

Study Design: OCM is a voluntary CMMI model that attempts to facilitate practice transformation for participating practices by aligning financial incentives to improve care coordination, increase beneficiary access to practitioners, and increase the use of appropriate clinical care. Under OCM, care is divided into six month episodes that begin on the date of an initial chemotherapy claim. There is no limit to the number of consecutive episodes that a beneficiary can trigger.

Throughout the episodes, participating physician practices are responsible for managing the spectrum of care furnished to oncology patients receiving chemotherapy. OCM practices receive a monthly enhanced service payment of $160 for attributed beneficiaries. Practices may also receive a performance-based payment if they achieve high scores on quality measures and reduce episode costs compared to a target.

Participating practices must provide enhanced services to FFS Medicare beneficiaries that include the following: 1) Patient navigation; 2) A care plan that contains the 13 components in the Institute of Medicine Care Management Plan; 3) Patient access 24/7 to an appropriate clinician who has real-time access to practice’s medical records; and 4) Treatment with therapies consistent with nationally recognized clinical guidelines. Practices must also use data to drive continuous quality improvement and use certified electronic health record technology.

The OCM evaluation utilizes a difference-in-difference approach as part of a mixed methods design. The evaluation uses CMS claims data, and interview and case study data from both intervention and comparison practices; it also leverages rich survey data to measure patient care experiences in a high mortality population.

Population: OCM participants are physician practices that furnish care for oncology patients undergoing chemotherapy and other treatment for cancer typically managed by a medical oncologist. Participants are carefully matched to similar non-participating practices for purposes of the evaluation.

Principal Findings: OCM launched in July 2016 with 192 practices and 14 payers. CMMI attempts to support the participants and understand their experiences through the use of webinars, project officer contacts, a help desk, and both practice and beneficiary-focused surveys. The evaluation’s combination of quantitative and qualitative data provides CMMI with clear results that are able to be interpreted by policy makers.

Conclusion: OCM and its corresponding evaluation are well positioned to improve oncology care and understand the clinical and financial drivers of success.

Implications for Policy, Practice, or Delivery: OCM provides CMMI with the opportunity to partner with oncologists in an attempt to improve the care delivered to complex Medicare beneficiaries with cancer and help move the Medicare program towards paying providers based on the quality of care they give patients.

Funding: Section 3021 of the Affordable Care Act