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Urology Practice Management - April 2015, Vol 4, No 2 - Payment Reform

A new payment model announced by the US Department of Health & Human Services offers providers the potential to receive at least $160 per month for patients who are undergoing chemotherapy treatment. The per-beneficiary, per-month (PBPM) allocation is part of a 2-pronged approach that also includes a performance-based payment to incentivize practices to reduce costs and improve care for this patient population. Hormonal therapies, including antiandrogen therapy used for the treatment of prostate cancer, are among the therapeutic regimens eligible for inclusion under this model.

The goal of this new model, known as the Oncology Care Model (OCM) and developed by the Centers for Medicare & Medicaid Services (CMS) Innovation Center, is to provide high-quality, well-coordinated, appropriately incentivized oncology care while controlling expenses and reducing costs, according to information provided by CMS. It also aligns with the US Department of Health & Human Services’ goal of moving toward provider payments that are based on quality of care, rather than quantity. It is estimated that more than 1.6 million people are diagnosed with cancer annually, the majority of whom are at least 65 years old and Medicare beneficiaries.

“Based on feedback from the medical, consumer and business communities, we are launching this new model of care to support clinicians’ work with their patients,” Patrick Conway, MD, CMS Chief Medical Officer and Deputy Administrator for Innovation and Quality, stated in a release announcing the new care model. “We aim to provide Medicare beneficiaries struggling with cancer with high-quality care around the clock and to reward doctors for the value, not volume, of care they provide. Improving the way we pay providers and deliver care to patients will result in healthier people.”

Through this model, CMS will provide qualifying providers with the $160 PBPM care management payment for each eligible beneficiary receiving chemotherapy and the care related to it. Payments will be made for the duration of a 6-month episode, hinged on the initiation of treatment with a preset list of chemotherapy drugs. Medications on this list include antiandrogen therapies that are used in the treatment of prostate cancer, as well as other hormone therapies related to treating this disease. A complete list of eligible drugs is provided in the program application, which is available by visiting the CMS website.

The PBPM payment will remain constant for OCM’s designated 5-year performance period, and comes in addition to fee-for-service payments. Eligible practices can be physician groups or solo practitioners who administer cancer chemotherapy and who are enrolled in Medicare. They must also meet the following requirements to participate in OCM and receive payment:

  • Provide core functions of patient navigation
  • Document a care plan that encompasses the Institute of Medicine Care Management Plan
  • Give patients around-the-clock access to an appropriate clinician who has real-time access to patient medical records
  • Treat patients according to nationally recognized clinical guidelines
  • Use data to drive quality improvement
  • Use electronic health records and attest to stage 2 of Meaningful Use by the third year of participation.

As part of their participation, practices must also report data quarterly to the CMS Innovation Center on eligible, participating beneficiaries. The Innovation Center will monitor participating practices to ensure that patients are accessing and receiving high-quality care, practices have the necessary infrastructure in place to deliver comprehensive care, and practices are submitting required data. Monitoring by the Innovation Center may include site visits, tracking and analysis of data, patient surveys, and medical record audits.
Payments may be billed to Medicare for the entire 6-month chemotherapy episode, whether or not the patient receives chemotherapy treatment for the full 6 months; payments cannot be billed to Medicare once the patient enters hospice. After an episode ends, another 6-month episode may be started if chemotherapy treatment is still active and being billed. Management of patients who are not receiving chemotherapy will not be eligible for this model.
The program is voluntary for oncology practices and payers, and CMS is asking for nonbinding letters of intent to gauge interest, due April 9 for payers and May 7 for practices. Those who submit completed, timely letters of intent will be eligible to submit final applications (due June 18). CMS is also encouraging participation from other payers, including commercial insurers, state Medicaid agencies, and other government payers. The agency will publicly post a list of payers who have submitted letters of intent and agreed to the posting; the agency will also post a list of practices, based on the same conditions.
Payers and practices will then have an opportunity to discuss and coordinate collaboration within the OCM. Provider applications will be evaluated using a process that favors those who are partnering with approved payers. The program is slated to begin in spring 2016, and applicants will be notified of their selection status within 6 months from the date they submit their application.

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Last modified: April 14, 2015
  • American Health and Drug Benefits
  • Association for Value Based Cancer Care
  • Lynx CME
  • Oncology Practice Management
  • Rheumatology Practice Management

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