Rough Start for Oncology Care Model

Tony Hagen @oncobiz
Published: Tuesday, Jul 12, 2016
Robert “Bo” Gamble

Robert “Bo” Gamble

Many oncology practices were motivated to join the Oncology Care Model (OCM) in order to keep up with the evolution of value-based care. But when the Center for Medicare & Medicaid Innovation (CMMI) started telling practices that their applications had been accepted, it was panic time for some, says Robert “Bo” Gamble, director of strategic practice initiatives for the Community Oncology Alliance (COA).

Officially launched this month, the OCM is designed to gradually introduce a risk-sharing arrangement that will put the pressure on practices to use their own Medicare and Medicaid billing history as the starting point for cutting costs and improving care. Not only that, practices will be expected to make improvements in coordinating and managing patient care with other providers. All of this includes an opportunity to share savings that are hoped for through this program. Eventually, oncology practices will have to undertake more revenue risk in order to avoid becoming subject to CMS’s new Meritbased Incentive Payment System.

Months ago, a core group of concerned practice representatives met with COA and went over the OCM. They were advised to create a brief list of major concerns they had about meeting the goals of the OCM. “We had about a dozen people, and they gave us a list of about 120 top priorities,” Gamble recalled. That prompted an “Oh, wow! This won’t work!’” But that was just the starting point. Gamble and others decided to pool their resources and get answers to the questions about how to make the OCM successful.

They created their own model that converted the CMMI OCM documents into a financial tool that could assist with budget requirements for OCM participation and also serve as a financial performance model. This collaborative resource was in turn shared with the 196 oncology groups— including hospitals and academic research centers—that have been accepted into the OCM program. “The OCM participation agreement includes some very specific conditions that if not followed will exclude the invitee,” Gamble said. “Most of these conditions were consistent with CMMI’s preliminary guidelines. However—and it may be due to wording or inadequate explanations—some teams discovered they were not in compliance and were scrambling at the last minute to determine how they could meet these criteria.”

Gamble indicates that the OCM Support Network, which COA has formed, has established a closed listserv—or e-mail notification system—and a bulletin board, and is holding monthly conference calls to address OCM difficulties. Also, a participant website will be created to house resources and documents. CMMI went public late last month with the names of the 196 practices and 17 payers that have agreed to be the first subjects in this latest alternative payment plan. The agency would not consent to an interview about the launch or the program. Practice administrators who spoke with Oncology Business Management about the transition said their primary concerns all along have been that the complexity of participating in a program of this type has been compounded by the difficulty of interpreting instructions from CMMI and its parent government agency, CMS.

Alternative Payment Models Are Not Going Away

However, there was general agreement among them that value-based programs are going to be a fact of life in the oncology world from now on. “It is our view that value-based care in some form or other is the basis for how reimbursement will be in the future, and we want to be on the front end of learning how to do it and how to optimize it,” said Barry Russo, CEO of the Center for Cancer and Blood Disorders (CCBD) in the Dallas-Fort Worth area of Texas.

There were other reasons for joining, too. Shawn Kienert, CFO of Fox Valley Hematology Oncology in Wisconsin, said it was partly altruism and peer pressure that motivated his practice to join the OCM. The OCM was viewed as “a really progressive idea.” In addition, the OCM offered a way to ward off the competition from other practices in the neighborhood, Kienert said. “If the guy across the street is going to lower his fees and I want to maintain my patients, I need to find a way to lower my fees to match.”

CCBD has struggled to interpret the OCM requirements and figure out how to make it all work, said Russo. That’s despite the fact that CCBD has already been working on value-based programs with UnitedHealthcare and Aetna and was involved in an Oncology Medical Home (OMH) pilot in 2012.

“What we’re finding with the OCM is that the biggest challenge is gathering the information on quality, clinical, and even demographic data that CMS is requiring us to report on a consistent basis,” Russo said. That information has been available in piecemeal format, but not in the automated stream that CMS has requested.

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