Oncology Care Model

Stage: Ongoing Number of Participants: 192 practices, 14 payers

Category: Episode-based Payment Initiatives Authority: Section 3021 of the Affordable Care Act

The Center for Medicare & Medicaid Innovation (CMS Innovation Center) is developing new payment and delivery models designed to improve the effectiveness and efficiency of specialty care. Among those specialty models is the Oncology Care Model, which aims to provide higher quality, more highly coordinated oncology care at the same or lower cost to Medicare. Under the Oncology Care Model (OCM), physician practices have entered into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients. The Centers for Medicare and Medicaid Services (CMS) is also partnering with commercial payers in the model. The practices participating in OCM have committed to providing enhanced services to Medicare beneficiaries such as care coordination, navigation, and national treatment guidelines for care.

Background

Cancer diagnoses comprise some of the most common and devastating diseases in the United States: more than 1.6 million people are diagnosed with cancer each year in this country. Through OCM, the CMS Innovation Center has the opportunity to achieve three goals in the care of this medically complex population: better care, smarter spending, and healthier people.

Model Details

The goal of OCM is to utilize appropriately aligned financial incentives to enable improved care coordination, appropriateness of care, and access to care for beneficiaries undergoing chemotherapy. OCM encourages participating practices to improve care and lower costs through an episode-based payment model that financially incentives high-quality, coordinated care. The CMS Innovation Center expects that these improvements will result in better care, smarter spending, and healthier people. Practitioners in OCM are expected to rely on the most current medical evidence and shared decision-making with beneficiaries to inform their recommendation about whether a beneficiary should receive chemotherapy treatment. OCM provides an incentive to participating physician practices to comprehensively and appropriately address the complex care needs of the beneficiary population receiving chemotherapy treatment, and heighten the focus on furnishing services that specifically improve the patient experience or health outcomes.

Seventeen commercial payers are participating in OCM in alignment with Medicare to create broader incentives for care transformation at the physician practice level. Aligned financial incentives that result from engaging multiple payers leverages the opportunity to transform care for oncology patients across a broader population. Other payers benefit from savings, better outcomes for their beneficiaries, and greater information around care quality. Participating payers have the flexibility to design their own payment incentives to support their beneficiaries, while aligning with the Innovation Center’s goals for care improvement and efficiency.

OCM incorporates a two-part payment system for participating practices, creating incentives to improve the quality of care and furnish enhanced services for beneficiaries who undergo chemotherapy treatment for a cancer diagnosis. The two forms of payment include a per-beneficiary Monthly Enhanced Oncology Services (MEOS) payment for the duration of the episode and the potential for a performance-based payment for episodes of chemotherapy care. The $160 MEOS payment assists participating practices in effectively managing and coordinating care for oncology patients during episodes of care, while the potential for performance-based payment incentives practices to lower the total cost of care and improve care for beneficiaries during treatment episodes.

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