CMS Announces OCM Successor, but Gap Year Remains for Oncology Practices

SAP Partners | <b>Community Oncology Alliance (COA)</b>

Today, CMS unveiled its plan for a successor to the Oncology Care Model (OCM), its ambitious foray into value-based care delivery that has been credited with changing the landscape for patients with cancer, even if it received mixed reviews on achieving savings in its early years.

Today, CMS unveiled its plan for a successor to the Oncology Care Model (OCM), its ambitious foray into value-based care delivery that has been credited with changing the landscape for patients with cancer, even if it received mixed reviews on achieving savings in its early years.

However, while the Biden administration addressed complaints that OCM fell short in addressing health disparities—and failed to reward practices that cared for the poorest patients—the new Enhancing Oncology Model (EOM) will not start until July 2023. As of today, the current OCM will expire on Thursday after 6 years.

“There are stark inequities in the ability of people with cancer across race, gender, region, and income to access cancer screening, diagnostics, and treatment,” said CMS Administrator Chiquita Brooks-LaSure. “CMS is working to advance President Biden’s Cancer Moonshot goals by helping Medicare cancer patients better navigate a challenging and often overwhelming journey. The Enhancing Oncology Model will incentivize participating oncology practices—including those in rural and underserved areas—to improve the provision of high quality, coordinated care that addresses patients’ social needs and improves patient and caregiver support.”

Ted Okon, executive director of the Community Oncology Alliance (COA), said the group was “disappointed” that the 1-year gap will occur, despite requests that CMS consider a reprieve for practices that had invested in the OCM and plan to move on to next model. “During this time practices will have to shoulder the extensive investments and operational changes put in place to benefit patients without reimbursement,” he said.

In addition, practices that have used OCM’s reporting system to comply with 2015 Medicare reforms may need to switch to a different framework until the EOM takes effect. The application period for the EOM opens today and continues until September 30, according to a CMS Fact Sheet.

The OCM was proposed by the Center for Medicare and Medicaid Innovation (CMMI) in 2015 and launched in 2016. It accomplished several things:

  • It required participating practices to offer several enhanced services, including 24/7 access to the patient’s medical records, use of a certified electronic heath record, patient navigation, a documented care plan including survivorship care, and treatment that followed clinical guidelines.
  • Practices had incentives to keep patients out of the hospital and the emergency department (ED), and most redesigned their phone trees and practice schedules to accommodate same-day, evening, or weekend appointments. More attention was paid to services such as nutrition that help keep patients out of the ED.
  • Practices had to develop systems for tracking and reporting patient quality data, which was needed for reimbursement.
  • Practices received both monthly payments based on episodes of care and periodic payments that reflected their ability to deliver quality care and achieve savings.

Leading oncology practices have said the OCM, while far from perfect, propelled them forward to make strides in practice transformation that would have been harder to achieve without Medicare’s leadership. Many commercial payers have developed their own versions of the OCM, and few can envision returning to care without services such as patient navigation or care planning.

CMS’ lack of nimbleness in the model's early years, as drug development outpaced the OCM’s pricing structures, led to tweaks and add-on payments to the underlying formula. Practices also said they had to get better at working with the model over time. In the later years of the OCM, the more sophisticated users turned the corner and produced significant savings for Medicare.

During a recent webinar, leaders from The US Oncology Network said the OCM had brought $240 million in savings for Medicare going into 2020, and the network had seen a 24% drop in ED visits and a 37% decrease in hospitalizations.

Physicians have acknowledged that the next incarnation of the model should address health equity, and Kashyap Patel, MD, president of COA, supported this change.

The EOM is proposed to run for 5 years through June 2028. It retains some key elements of the OCM; notably, it will be voluntary, not mandatory. It retains the basic structure of the OCM, with 6-month care episodes and requirements for enhanced services, and a 2-part reimbursement structure: monthly payments tied to episodes of care, and backward-looking performance based payments based on quality measures and demonstrated savings.

However, there are some major differences. According to the information from CMS, the model will cover Medicare patients undergoing chemotherapy for major cancer types: breast cancer, chronic leukemia, lung cancer, lymphoma, multiple myeloma, prostate cancer, and small intestine/colorectal cancer. The OCM covered nearly all types of cancer.

Many of the changes are not surprises: the EOM will also add requirements for electronic patient reported outcomes (ePROs). Some will be welcomed by practices that serve budget-conscious patients: no co-payments will be required for enhanced services.

As expected, a major focus of the EOM is addressing health equity: the model will include additional payments to oncology practices for patients who qualify for both Medicare and Medicaid. Practices must report demographic data and outline plans to address health equity. But Okon said COA was surprised that the monthly episode-based payment will drop from $160 to $70, cutting revenue for practices when the scope of work will increase.

“Community oncology practices are fully committed to positive, patient-centered improvement of cancer care and look forward to supporting CMMI and practices to make the EOM a success,” Okon said. “The goals of the EOM are ones we wholeheartedly support, especially related to improving cancer health equity, electronic patient reported outcomes, enhanced access to cancer screenings, and more.”