New Medicare Payment Model to Reward Coordinated, Patient-Centered Cancer Care

February 18, 2015
Lauren M. Green

The Center for Medicare & Medicaid Services (CMS) has announced a new initiative which it hopes will improve the coordination and quality of cancer care for Medicare patients with cancer while also reducing costs.

Patrick Conway, MD

The Center for Medicare & Medicaid Services (CMS) has announced a new initiative which it hopes will improve the coordination and quality of cancer care for Medicare patients while also reducing costs.

The Oncology Care Model (OCM), set to launch next year, was developed by the CMS Innovation Center with feedback from the oncology community, patient advocates, and the private sector.

“We aim to provide Medicare beneficiaries struggling with cancer with high-quality care around the clock and to reward doctors for the value, not volume, of care they provide. Improving the way we pay providers and deliver care to patients will result in healthier people,” Patrick Conway, MD, CMS chief medical officer, said in a statement.

Patient Navigation at the Core

Practices who participate in the OCM program must provide the core functions of patient navigation. Participating providers also must provide patients with 24/7 access to a clinician who can readily consult patient records to help manage symptoms and side effects and avoid hospitalizations.

In addition, patients must be treated with therapies consistent with nationally recognized clinical guidelines, and practices must use an approved electronic health record consistent with meaningful use requirements.

The program will provide a two-part, episode- and performance-based payment approach: (1) a monthly $160 per-beneficiary care management (PBPM) payment for Medicare fee-for-service beneficiaries, and 2) a performance-based payment for OCM episodes. The PBPM payment for enhanced services is designed to support the cost of managing and coordinating care for Medicare patients. It is hoped that a performance-based payment will incentivize participating practices to improve care for beneficiaries and lower the total cost of care.

In announcing the new program, CMS noted that the majority of those diagnosed with cancer in the United States are over 65 years old on Medicare. “With the Oncology Care Model, CMS has the opportunity to achieve three goals in the care of this medically complex population who are facing a cancer diagnosis: better care, smarter spending, and healthier people,” said Conway.

“As a practicing physician and son of a Medicare beneficiary who died from cancer, I know the importance of well-coordinated care focused on the patient’s needs.”

The National Coalition for Cancer Survivorship (NCCS) praised the OCM as being in line with its goal that all patients receive a cancer care plan to guide their treatment and help coordinate their care.

“NCCS advocates for access to the best possible cancer care for all people with cancer, and we believe the Oncology Care Model offers cancer patients the hope of better, more coordinated care,” said NCCS CEO Shelley Fuld Nasso in a statement. “Cancer treatment is never easy, and the challenge of navigating a complex healthcare system is an additional burden for cancer patients to bear. Anyone who has experienced the healthcare system understands that we can do better for patients.”

Payment Reforms Needed, Too

The Community Oncology Alliance (COA) concurred that the OCM is a step in the right direction, but it needs to be supported by broader reforms.

“The model proposed by CMMI [Center for Medicare & Medicaid Innovation] is generally consistent with COA’s Oncology Medical Home payment model, although there are some questions and concerns that we need to address with CMMI, which has been very open to input,” the organization said in a statement. “It is critical that payment reform … must also be concurrent with an immediate fix to Medicare drug payments or all this payment reform will be for naught.”

While commending CMS for seeking new approaches to physician payment, the American Society of Clinical Oncology (ASCO) expressed concerns over the model’s limited scope. “We are disappointed they have chosen to pursue only one model—and one that continues to rely on a broken fee-for-service system," said ASCO Chief Medical Officer Richard Schilsky, MD, FACP, FASCO.

In comments submitted to CMS on a draft version of its model, ASCO supported testing OCM as well as other payment reform models to determine new approaches to payment for oncology care. Moreover, ASCO urged the center to test models that include more fundamental reform that moves away from the fee-for-service system. "ASCO looks forward to working with both public and private payers to explore new payment strategies that better reflect modern oncology practice and support high value, patient-centered care,” said Schilsky.

The OCM represents the second in a series of specialty care models of Medicare payment. It follows the start last year of the Comprehensive ESRD Care Model for enhanced care to beneficiaries with end stage renal disease.