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Achieving Data-Driven Success Under the Oncology Care Model

Kelly Price is Vice President and Chief of Healthcare Data Analytics at DataGen, a healthcare data analytics and policy firm. Kelly has worked in healthcare finance for more than 20 years, focused on helping healthcare leaders and decision makers understand the impact of payment policy and regulations on their organizations. She provides decision support and education to hospitals and health systems across the country to help them prepare for the shift to value-based payment. Kelly works with hospital associations in 47 states and eight multi-state systems on Medicare and Medicaid reimbursement issues.
This article has been coauthored by Alyssa Dahl, principal healthcare informatics analyst, DataGen.

If recent trends continue, the cost of cancer care in the United States will reach $172.8 billion in 2020, a 39% increase from 2010, according to a 2011 study from the National Cancer Institute. The government is responding with several new payment models, including the Medicare Shared Savings Program, Comprehensive Primary Care Plus, and the Oncology Care Model (OCM).
Alyssa Dahl, Principal Healthcare Informatics Analyst, DataGenAnnounced by CMS in January 2015, OCM is one of the most recent programs in a litany of new experiments. Hospitals and other healthcare providers that are participating in any of these programs will find it challenging to effectively evaluate and manage their activities so as to improve the effectiveness and efficiency of care and optimize the patient experience. These providers will need to review and monitor their data to determine the possibilities for success in bundled payment programs and to measure the value of participation.

Should You Participate in the OCM?
The OCM program is a 5-year alternative payment model (APM) for oncology practices and independent practitioners. It begins on July 1 of this year and provides 3 forms of reimbursement for participants: a traditional fee-for-service payment for Medicare Part A, B, and D services; a per-beneficiary-per-month (PBPM) payment for the duration of  each 6-month episode, and the potential for a retrospective, risk-adjusted payment based on performance quality metrics and actual care cost savings.
Practices submitted applications last Fall and received notifications at the end of March announcing whether their applications were accepted, but they only have a short window within which to accept the participation agreement. In addition to achieving cost efficiencies, participants must meet 6 practice requirements:
  1. Provide 24/7 patient access to appropriate clinicians
  2. Be a meaningful user of certified electronic health records
  3. Utilize data for continuous quality improvement
  4. Provide patient navigation
  5. Document a care plan for every OCM patient
  6. Treat patients with therapies that are consistent with nationally recognized clinical guidelines
If a practice is already planning to invest in these 6 OCM requirements, that is a good indicator that participation will be worthwhile. However, there are some risks that practices should understand:
  1. Practices may spend more than the PBPM payment to achieve the program requirements
  2. Care transformation efforts may not be enough to qualify for a performance bonus
  3. The bonus a practice qualifies for may not be large enough to offset costs
On the other hand, practices will gain experience managing risk, will have the opportunity to influence future Medicare oncology programs, and will have access to performance data with which they can benchmark themselves against past performance and identify areas for improvement. Additionally, practices can choose if they want to accept downside risk, though the Medicare spend-per-episode target is set lower if they decide to avoid that risk. Determining which option is right for your organization will require specialized expertise in healthcare analytics and an understanding of the mechanics of episodes of care at all levels of the organization.

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