Quality Metrics for Oncology in a Value-Based Reimbursement World

Published on: 
Evidence-Based Oncology, June 2016, Volume 22, Issue SP8

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.

Electronic Health Record

Care coordination requires communication among service providers in order to track hospital admissions (including the number of Intensive Care admissions), hospital readmissions, emergency department visits, and/or hospice admissions. Tracking of this information extends beyond the treatment phase to 6 months following the OCM FFS episode of care.

Compatibility among the reporting systems of the diagnostic service providers, such as a hospital or an independent reference laboratory, interpreting physicians (eg, pathologist, radiology), or genetic counselors is essential. This ensures that everyone involved has access to necessary diagnostic information including “specific tissue information, relevant biomarkers, and stage.”

Remember: Participating providers must attest to their accessibility 24/7, the effective use of EHRs, and real-time access to the medical record and comprehensive plans.


Specific quality measures are in place for colorectal cancer and breast cancer. Clinical quality-of-care monitoring is outlined for colon cancer, breast cancer, and prostate cancer. All quality measures required by the program must be documented by the participating providers and reported to CMS. (Required components can be found in Appendix C of the OCM request for application.) A provider’s reimbursement could decrease if the required quality measures are not reported.

We have found that quality data collection and reporting done by different staff utilizing different processes results in an uncoordinated effort. When everyone works in their own silos, the reported data often conflicts and not everyone collecting that data fully understands what it means. The goal, instead, is for those involved to understand how their piece of the quality puzzle affects others pieces. They also must understand all of the processes related to quality data collection and reporting. The following steps may help achieve that goal:

  • Identify a multidisciplinary team to develop workflow and shared processes. It is critical to establish a single point of reference for providers. Be sure to promote a culture of transparency and integrity. It is important that your team members understand what your data is showing so that they know how to address issues and opportunities that may be identified.
  • Perform an operational review of all quality data collection and reporting functions in each relevant practice area. Assess data collection and reporting processes, as well as the actual data reporting and outcomes. It is important to ensure that processes are working and that everyone understands what your data is showing.
  • Consider a focused review (internal and/or external) of all reporting and audit mechanisms to eliminate duplicate efforts. Ensure consistent data reporting by investing in a comprehensive system. Develop a corrective action plan for your practice that includes documentation guidelines and clinical definitions for nonclinical and clinical staff. Use technology whenever you can to work more efficiently, but be careful not to become too technology-dependent. You still need a person to interpret and analyze the data.
  • Assess documentation and EHR capabilities at your practice. Is your EHR optimally set up for collecting quality data?
  • From a financial perspective, it is important to know where your practice stands on each selected measure for the baseline period and identify which measures have the best rate of return. You also want to ensure that your pricing is competitive and defensible.
  • Educate your entire multidisciplinary team. All staff should have a baseline starting point and a way to maintain their knowledge levels, as quality-related information is being released sometimes on a daily basis.

In conclusion, practices must begin to review their quality practices and data collection on an annual basis much like they review their other processes (such as coding and charge masters). External auditors could be brought in to conduct reviews once a year, supplemented by an internal team, with one person assigned to lead and coordinate. This will be the only way to ensure that processes are working optimally and data is being reported accurately.


While this article has focused on the OCM for physicians, it is important to look ahead and be prepared for similar programs on the hospital side, which CMS addressed in the proposed rules for the 2016 Hospital Outpatient Prospective Payment System.10 Insights of topics that may be targeted in the future can be found in the comments submitted by the American Society of Clinical Oncology (ASCO) to CMS on August 31, 2015. ASCO focused on reimbursement for cancer drugs, packaging of drugs and drug administration add-on codes, and increasing high-quality, high-value cancer care in outpatient hospital settings.11

Author information

Kim Charland, BA, RHIT, CCS, is senior vice president, Clinical Innovation and publisher of VBPmonitor, Panacea Healthcare Solutions.

Robin Zweifel, BS, MT (ASCP) is senior vice president, Revenue Capture Services, Panacea Healthcare Solutions.

Address for correspondence

Kim Charland, BA, RHIT, CCS

Senior Vice President of Clinical Innovation

Panacea Healthcare Solutions

287 East Sixth Street

Suite 400

St. Paul, MN 55101



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  2. Hospital value-based purchasing. CMS website. Updated October 30, 2015. Accessed May 23, 2016.
  3. Readmissions reduction program. CMS website. Updated April 18, 2016. Accessed May 23, 2016.
  4. Cancer facts and figures 2014. American Cancer Society website. Accessed May 23, 2016.
  5. Oncology care model fact sheet. CMS website. Published February 12, 2015. Accessed May 23, 2016.
  6. Bach PB, Conti RM, Muller RJ, Schnorr GC, Saltz LB. Overspending driven by oversized single dose vials of cancer drugs. BMJ. 2016;352:i788. doi:10.1136/bmj.i788.
  7. Oncology Care Model. CMS website. Updated March 3, 2016. Accessed May 23, 2016.
  8. Oncology Care Model, request for applications, February 2015. CMS website. Updated June 3, 2015. Accessed May 23, 2016.
  9. Medicare drug spending dashboard 2014. CMS website. Accessed May 23, 2016.
  10. Department of Health and Human Services. Federal Register. 2015;80(130). Published July 8, 2015. Accessed May 23, 2016.
  11. ASCO responds to proposed rules on 2016 hospital outpatient prospective payment system. American Society of Clinical Oncology website. Published September 1, 2015. Accessed May 22, 2016.