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OCM Practices Struggle with CMS Report Cards

Natalie Pompilio
When the CMS released performance reports for the 181 practices enrolled in the Oncology Care Model (OCM) earlier this year, the action had the effect of creating as much confusion as it resolved. 
When the Centers for Medicare & Medicaid Services (CMS) released performance reports for the 181 practices enrolled in the Oncology Care Model (OCM) earlier this year, the action had the effect of creating as much confusion as it resolved. Practices were looking forward to finding out whether they qualified for bonus payments for exceptional performance. What some found out, however, was that they had to pay money back to CMS. Now, as participating practices anticipate the second round of performance reports, due at the end of August, they hope things will go more smoothly.

Two years into the OCM pilot, practices in February received their performance period 1 (PP1) reconciliation reports—detailed accounts regarding the 6-month period from July to December 2016 when the 5-year OCM pilot was initiated. Some practices were unhappy with not only the reports’ conclusions and the methodology used by CMS but also the fact that they learned their full PP1 results just as period 4 got under way.

“You don’t know how you’re going to be judged, and you just got the results from more than a year ago,” said Bo Gamble, director of strategic practice initiatives for the Community Oncology Alliance (COA). “It’s so complicated, people can’t make timely, conscious decisions about how to improve their care while lowering costs.” The OCM is a patient-centric program that CMS says will allow for “better care, smarter spending, and healthier people.” It aims to move practices from volume-based to value-based care by structuring Medicare payments around the full range of services an oncology patient needs. A practice that can both provide good treatment and spend less money than Medicare expected will be financially rewarded.

Other requirements for participating practices include giving each patient a 13-point care plan, recording patient information in a central database, and offering patients aroundthe- clock access to a clinician who can access medical records quickly. CMS provides monthly enhanced oncology services (MEOS) payments of $160 per patient per month to help practices institute necessary changes. The bulk of savings is expected to come from fewer hospital stays and emergency department (ED) visits and better use of hospice and palliative care options. 

Figure. CMS' Timing of Performance Reconciliation Reports has Caused Adjustment Difficulties for Practices

Performance Payments
Barbara McAneny, MD, a managing partner of New Mexico Oncology Hematology Consultants Ltd and president of the American Medical Association, said her practice was among those that received a $23,000 performance-based payment for achieving savings below the targets set by CMS.

About 25% of participating practices received such payments, according to the Center for Medicare and Medicaid Innovation (CMMI); however, COA estimates that those particular practices account for just 10% to 15% of patients and doctors. Gamble said that based on an informal COA poll, just 15% of responding practices received performance-based payments.

Although practices were happy to receive performance-based payments, many were dismayed to find that they had to return MEOS payments, which oncologists receive only if they are their patients’ primary care physicians. When patients see other physicians for health issues, CMS assigns or “attributes” the patient to the doctor who provided the most in-office care. CMS calculated that some oncologists had not served as primary care providers and asked for the money back. Some practices successfully appealed and got the MEOS payment cuts reduced.

Terrill Jordan, president and chief executive officer (CEO) of Regional Cancer Care Associates, which has 110 physicians and 30 local offices in Maryland, New Jersey, and Connecticut, said that about 27% of the network’s patients were attributed to other doctors. After an appeal to CMS, that figure fell to about 16%. “We provided coordinated care to a large group of patients who were not attributed to us, and we did not get full payment for this work,” Jordan said. “You can imagine our discomfort with that result.”

McAneny’s practice had to return $11,000. Even with the performance-based payment, she said, losing the MEOS funds for patients who’d received her practice’s treatment was a tough hit financially. She believed her practice qualified for a performance- based payment in part because it was already doing much of what the OCM required, she said. Still, making the switch to the OCM was costly; to meet the electronic health record requirements, the practice had to pay a large amount of overtime to staff members. “If we truly added up what it cost to do this model, the MEOS payments were insufficient,” she said.

She also contends the formula Medicare uses to determine an individual patient’s care costs does not adequately address rising drug prices or new therapies. McAneny said this discourages physicians from using expensive drugs and punishes those who take on patients with more complex health problems.

“If you came in with a melanoma and I treated you with standard old chemotherapy, you’d be dead in 3 months,” McAneny said. “If I treat you with the new expensive drug that costs $100,000 per year, you could live for years. Not to use that drug would be unethical, but I would get punished [financially]. If I get a lot of people who are inexpensive to take care of, then I look like a genius because I saved money. If I go over the target, I’m a bad doctor and I’m losing money.”

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