Andrew York, PharmD, JD, Center for Medicare and Medicaid Innovation (CMMI) , Centers for Medicare and Medicaid Services (CMS), provided an update on the role of quality improvement in oncology value-based payment, with specific attention to Oncology Care Model (OCM) Quality Measures.
Mr York gave his presentation at the Clinical Pathways Congress (October 27, 2018; Boston, MA).
He began his presentation with an overview of the OCM, including the goals and theory of action of the program. The OCM, he explain, is a 5-year plan that utilizes real-time monthly payments for enhanced services for beneficiaries combined with Medicare fee-for-service payments. It also offers the potential for a retrospective performance-based payment based on quality and savings.
Mr York explained that the scope of the OCM consists of approximately 25% of Medicare fee-for-service chemotherapy-related cancer care, including 184 practices, more than 6500 practitioners, more than 150,000 unique beneficiaries per year, and more than 200,000 episodes of care per year. Thirteen commercial payers are participating, he noted.
In terms of the practice redesigning activities, Mr York detailed the OCM’s providing of beneficiaries with enhanced services, utilizing of certified electronic health record technology, and utilizing of data for continuous quality improvement. However, there are numerous challenges of developing a Medicare alternative payment model in oncology, he noted, highlighting the complexity and diversity of clinical cancer care, limitations of Medicare claims system, complexity of practice business models, and complexity and limitations of ICD coding systems, all of which are taken into consideration in the development of the OCM.
The conversation then turned toward the fee-for-service two-part payment approach. He explained that while participating practices continue to be paid Medicare fee-for-service payments during the OCM, the model also requires a two-part payment approach involving a monthly enhanced oncology services (MEOS) payment and performance-based payment. The performance-based payment is calculated retrospectively on a semi-annual basis and is based on a practice’s achievement on quality measures and reductions in Medicare expenditures below a target price.