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Quality Metrics for Oncology in a Value-Based Reimbursement World

Kim Charland, BA, RHIT, CCS, and Robin Zweifel, BS, MT (ASCP)
CMS has developed the Oncology Care Model (OCM) to provide physician practices that furnish chemotherapy treatment the option of payment arrangements that include financial and performance accountability for episodes of care for cancer patients. This article presents an overview of the model and guidelines that can help meet the quality and performance measures for OCM participation.

Healthcare is rapidly transitioning from a fee-for-service (FFS) to a value-based reimbursement world. This transition accelerated when, in January 2015, HHS announced a new set of goals and a timeline for tying Medicare payments to quality or value through alternative payment models.1
HHS goals included linking 30% (up from 20%) of traditional Medicare payments by the end of 2016 through accountable care organizations and bundled payments, and 50% by the end of 2018. HHS also set a goal of linking 85% of all traditional Medicare payments to quality or value by 2016, and 90% by 2018 through programs such as Hospital Value-Based Purchasing2 and the Hospital Readmission Reduction Program.3
What Does This Mean for Oncology Services?
Cancer is one of the most common diseases in the United States, with more than 1.6 million individuals receiving a cancer diagnosis each year. About 77% of all cancers are diagnosed in people 55 years and older.4 According to the Centers for Medicare & Medicaid Services (CMS),5 the majority of those diagnosed are over 65 years and Medicare beneficiaries.
A British Medical Journal6 article reported that the waste from cancer drugs costs Medicare and private insurers billions of dollars each year. In addition, chemotherapy services can include many post-acute care services (eg, physician follow-up visits, medication management, laboratory services, home care, hospice, etc) and impact the patient’s quality of care, requiring a high level of care coordination between the various providers and services. Based on the HHS goals to increase quality-of-care outcomes and improve patient satisfaction while reducing costs, it is clear why the CMS chose oncology services as one of its specialty care models. (The first was the Comprehensive End-stage Renal Disease Care Model.)
The Oncology Care Model (OCM) is a multi-payer model where physician practices enter into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients.7 The goal of this model is to provide higher-quality and more coordinated oncology care at a lower cost.
The OCM—a 5-year model with plans to begin in the spring of 2016—combines financial incentives, including performance-based payments, to improve care coordination, appropriateness of care, and access for beneficiaries undergoing chemotherapy. It will target beneficiaries receiving chemotherapy treatment and the spectrum of care provided to a patient during a 6-month episode following the start of chemotherapy. Physician practices that furnish chemotherapy treatment may also participate in the OCM.
Participating physician practices will be eligible for 3 payments under the OCM:
  • Regular FFS payments (including average sales price + 6% for drugs and biologicals)
  • $160 per-beneficiary-per-month payment for care management (up to $960 per beneficiary per episode)
  • Performance-based payment where participants may receive up to the full difference between a target spending price and their actual expenditures, based on their performance on a range of quality measures. This payment offers an opportunity to share in the savings from this model.
The OCM requires that participating physician practices meet certain practice transformation requirements to improve management and coordination of care. They include the following:
  • 24/7 patient access to a clinician who has real-time access to the practice’s medical records
  • Attestation and use of the Office of the National Coordinator for Health Information Technology–certified electronic health record (EHR)
  • Utilize data for continuous quality improvement
  • Provide core functions of patient navigation
  • Document care in accordance with the Health and Medicine Division (HMD; formerly Institute of Medicine) Care Management Plan
  • Treat patients with therapies consistent with nationally recognized clinical guidelines.
Physician practices also will be required to meet certain quality and performance measures to receive their performance-based payment. CMS provided a primary list of over 30 quality metrics and indicated that it will continue to work with stakeholders to finalize a reasonable set of measures. A complete list of quality and performance measures can be found on pages 25 to 28 of the OCM Request for Applications.8
Adopting Quality Standards
So what can physician oncology practices be doing from a quality-metric perspective to ensure appropriate documentation and reporting of chemotherapy services? There are several processes to consider adopting, including the following.
Responsible Staff Members
Participating practices must be adequately staffed and prepared to coordinate appointments for diagnostic and therapeutic services. When indicated, the practice must ensure that the complete medical record is available at the time of all scheduled appointments. Coordination of care will include maintaining communication with the patient and/or family members. At times it may be necessary to arrange for, or assist with arrangements for, translation or interpretation services, transportation to/ from appointments, child care or elder care, follow-up service, and financial support. The provider or staff may be called upon to provide access to clinical trials, to advise on participation in a trial, or to provide referral to services such as support groups. Additionally, processes must be in place to monitor patient satisfaction levels.
Participation in the OCM requires development of a plan that contains the 13 components listed in the HMD Care Management Plan for each patient participant. The provider’s determination to follow a nationally recognized clinical guideline or to deviate from the clinical guidelines for a particular patient should be explained within the record. An explanation that justifies the clinical decision making that impacted the treatment choice for each patient (eg, participation in a clinical trial) should be included. The care plan should reflect the patient’s participation in its development and should refer to the patient’s decision to move forward with the chemotherapy treatment plan.
Be sure to include information that provides an estimated total of the treatment cost and the expected out-of-pocket costs to be paid by the patient. Depending on the drug regimen, it is possible that the Medicare drug spending9 dashboard would provide supporting data; it may address drug-specific estimates for per-patient annual spending and the average annual beneficiary cost share for Part B and Part D prescription drugs being studied by Medicare due to the high cost.

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