How the Oncology Care Model is Changing the Trajectory of Cancer Care

Oncologists participating in the Oncology Care Model (OCM) are attempting to reform their practices to deliver higher quality care at a lower cost, according to new analysis.

The OCM, the Center for Medicare & Medicaid Innovation (CMMI) program, is a voluntary five-year bundled program designed to provide higher-quality, better coordinated cancer care at the same or lower cost to Medicare beneficiaries.

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Analysis from Avalere shows that 21% of cancer patients in Medicare Part B fee-for-service (FFS) were treated by an oncology practice participating in the OCM in 2017. The proportion of cancer patients in Medicare Part B FFS being treated by an OCM doctor varied between 12% and 30% in 2017, depending on type of cancer. Among the more common types of cancer, more than 25% of patients with breast and lung cancers and 12% of patients with prostate cancer were treated by a doctor participating in the OCM.

“The OCM seeks to change cancer care practices to drive greater value. Because of the OCM, oncologists are changing their practices in order to improve quality of care while maximizing resources,” says Sung Hee Choe, Avalere vice president. “The effect is not only for patients enrolled in the OCM but for all oncology patients.”

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Avalere analyzed Medicare Part B FFS claims for 2017 under a CMS research data use agreement. Avalere analyzed a cohort of patients including all cancer patients receiving cancer treatment that represents less than 20% of total beneficiaries.  Beneficiaries were defined as those to be receiving cancer treatment if they received two or more physician evaluation and management (E&M) visits with a cancer diagnosis during the year.

Avalere identified E&M visits with a cancer diagnosis in the same way it is defined in the OCM, using Part B carrier claims with a HCPCS code in the range of 99201-99205 (new patient visit) or 99211-99215 (established patient visit).

For cancer diagnoses, the researchers limited their analysis to the cancer types that are in the OCM program. Avalere defined each patient’s type of cancer using the same ICD-10 mapping used in the OCM. For patients having multiple types of cancers in 2017, researchers determined their cancer type based on the diagnosis appearing on the plurality of their E&M visits during the year. (In the event that no cancer diagnosis had a plurality of E&M visits, they used the diagnosis on the patient’s last E&M visit in 2017.) The OCM uses a similar plurality approach when determining the type of cancer for an episode.

Doctors participating in OCM are treating more of some cancer types than others, such as breast and lung cancers. “As such, the OCM may be accelerating oncology practice transformation for some cancers more than others,” Choe says.

“Healthcare executives should understand how oncology practices are evolving their practices in response to the OCM, specifically around utilization of healthcare resources, and the effect on provider performance and patient outcomes,” says Choe. “While OCM is a Medicare model, practices are changing procedures for all patients. In addition, how practices are responding to OCM could be instructive on the challenges and opportunities to implementing alternative payment models in specialties beyond oncology.”

The OCM is a voluntary five-year bundled payment program developed by the Center for Medicare & Medicaid Innovation (CMMI). Started in 2016, the OCM is one of the first physician-led specialty care models created by CMMI with the aim to improve quality and reduce the cost of care. There are 184 oncology practices, representing more than 6,500 practitioners, and 13 payers across the US participating in the model.

OCM participants are eligible to receive performance-based payments for 21 types of cancers, as well as monthly enhanced oncology service (MEOS) payments for these 21 cancers and a group of less common cancer types. Avalere experts estimate there were 2.2 million patients with these types of cancers in Medicare Part B FFS in 2017. Among them, Avalere estimates 472,000 patients (or 21%) received care from a doctor participating in the OCM.