**Disclaimer**: The materials on this page provide information on the history, background, and roll out of the CMMI Oncology Care Model and likely contain out-of-date information.
Oncology Care Model Background
Application Process and Timeline (Updated June 5, 2015)
Providers must have submitted a non-binding letter of intent (LOI) by the 5 pm ET, May 7 deadline in order to submit an application to participate in the Oncology Care Model (OCM). All practices that submitted an LOI will be sent an authenticated web link to access the OCM application.
CMS will post a list of practices that submitted LOIs and agreed to a public posting on May 14 to allow interested payers and practices to coordinate their participation in the OCM.
Final applications are due by 5 pm ET, June 30, 2015.
CMS will notify practices of their selection within six months of the application deadline, and at that time will make benchmark prices and other baseline data available to practices prior to signing participation agreements, which will serve as binding agreements between participants and CMS.
The OCM is set to begin in spring 2016. The OCM is a five-year model.
Submitted an LOI?
Before completing your application, use the CMS application template* to start thinking about your answers: Oncology Care Model Practice Application Template
*Remember this template is only for reference. This will not be accepted by CMS! To submit an application, use the web link and password that you received from CMS on completion of your LOI to submit an application.
Provider Selection Criteria
CMS has announced the following scoring methodology for applications:
- Implementation Plan (40 Points)
Full description of the practice’s plan for the first two OCM performance years, including current and proposed implementation of practice requirements.
- Financial Plan (25 points)
Full description of the practice’s financial plan to support the implementation plan for the first two OCM performance years, including use of PBPM payments, expected performance-based payments, and expected payments from other payers.
- Participation with Other Payers (i.e., other than Medicare) (30 points)
Letters or explanations of support from payers with which the practice wishes to participate in OCM.
- Diverse Populations (5 points)
Practice’s plan to treat and engage diverse and/or underserved populations (including dual eligible beneficiaries) during OCM.
*For more information, see page 21, table 1 of the RFA.
Why Participate in the Oncology Care Model?
ACCC members will need to evaluate their individual clinical, administrative, and financial infrastructure to decide whether the OCM is the right program for you.
Opportunity for Shared Savings
OCM’s payment structure creates incentives to improve the quality of care and furnish enhanced services for beneficiaries who undergo chemotherapy treatment for a cancer diagnosis. Participating practices will be eligible for three payments under the OCM:
- Regular fee-for-service (FFS) payments (including ASP+6% for drugs and biologics)—practices will continue to bill Medicare FFS claims throughout the episode
- $160 per-beneficiary, per-month payment (PBPM) for care management (up to $960 per beneficiary per episode)
- Performance-based payment – 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.
Opportunity to Gain Experience with New Models
Developing, implementing, and evaluating innovative ways to pay providers and transform care delivery has been a top priority for CMS in recent years. Alternative payment models (APMs) that tie payments to quality and value are increasingly being adopted by public and private payers, and, more and more, providers will be expected to take on risk to care for their patients. The OCM is an opportunity for the oncology community to gain experience with new financial and clinical arrangements, continue to improve their infrastructure, and learn best practices from their colleagues.
Who is Eligible to Participate in the Oncology Care Model?
Physician group practices, hospital-based practices, and solo practitioners can all participate!
CMS expects to enroll diverse practices. Physician group practices and solo practitioners that furnish chemotherapy for cancer are eligible to participate. Eligible practices may be multi-specialty practices and do not need to solely consist of physicians that furnish cancer chemotherapy.
CMS has provided clarification that hospital-owned practices, practices that partner with a hospital outpatient department for chemotherapy infusion services, as well as practices owned or formally affiliated with hospitals that participate in the 340B Drug Pricing Program are all eligible to participate.
How Will My Services Be Reimbursed?
As mentioned above, in addition to standard FFS payments, participants will also receive a monthly per-beneficiary-per-month (PBPM) payment for the duration of the beneficiary’s episode. Participants are also eligible for semi-annual lump-sum performance-based payments.
Total Potential OCM Participant Payments:
- Standard FFS payments (including ASP+6% for drugs and biologics)
- $160 PBPM payment for enhanced care coordination
- Performance-based payment (portion of Medicare savings and achievement of quality measures).
What are the Requirements of the Oncology Care Model?
Practice Transformation Requirements: OCM requires that participating practices meet certain practice transformation requirements by the end of the first quarter of the first performance year. The requirements are intended to improve management and coordination of care.
Six Practice Transformation Requirements:
- Patient access 24/7 to clinician who has real time access to practice’s medical record
- Attestation and use of ONC-certified EMR
- Utilize data for Continuous Quality Improvement (CQI)
- Provide core functions of patient navigation
- Document care plan in accordance with the Institute of Medicine (IOM) Care Management Plan outlined in the report, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis"
- Treat patients with therapies consistent with nationally recognized clinical guidelines
Quality Metrics: Practices will also be required to meet certain quality and performance measures to receive their performance-based payment. CMMI provided a preliminary list of over 30 quality metrics, and plans to continue to work with stakeholders to finalize a reasonable set of measures.
Can Payers Participate in the Oncology Care Model?
The OCM is a “multi-payer” structure, which means, in addition to Medicare, commercial payers, state Medicaid agencies, and other governmental payers may apply to participate. CMS strongly encourages practices to partner with another payer to leverage the opportunity to improve care for oncology patients across the population.
Oncology Care Model Practice LOI Submission List
The Center for Medicare and Medicaid Innovation has released the list of physician practices that have submitted Letters of Intent (LOIs) to participate in CMS’s first-ever oncology-specific payment reform model, the Oncology Care Model. The list includes 443 diverse practices, many of which are ACCC members. Submission of an LOI was the first step in applying to participate in the model; final applications were due by June 30, 2015. According to CMS, the agency hopes to enroll 100 diverse practices.
ACCC members have engaged in an ongoing dialogue with CMS as they consider whether the OCM is right for their practice. CMS’ attempts to clarify some of the top issues for our members are listed below. We welcome your ongoing feedback on the OCM as we continue our dialogue with CMS.
CMS has advised that provider performance improvements will be calculated based on the specific practice’s past performance, likely over a three-year period beginning in 2012. This baseline will remain for the entire five-year period of the OCM, so as not to penalize practices that quickly adopt practice improvements. In establishing target prices, CMS indicates that it will continue to develop a methodology to account for the high cost of new drugs and technologies. CMS will share that methodology before practices must sign participation agreements.
The OCM will evaluate providers based on the total cost of care during a patient episode, beyond just oncology care. In response to provider concerns about extremely high-cost patients, CMS has indicated it will use a statistical method, called Winsorization, to minimize variability and ensure practices are not unfairly penalized for treating complex patients.
While benchmarks will be risk adjusted, adjusted for geographic variation, and trended forward to each model performance year, the risk-adjustment factors will only include those in administrative claims data. CMS will collect additional information from practices, including cancer staging information, to consider as risk-adjustment factors in future OCM performance years.
Partnering with Payers
CMS has announced that 48 payers have submitted LOIs. The payers are geographically diverse, and a list of participating payers can be found here.
While it is an advantage for provider practices to partner with other payers (30/100 points in the selection process), CMS has stated it is possible for a practice to be selected to participate in the OCM with Medicare as its only payer. Payers may also be able to expand coverage regions after provider Letters of Intent are made public.
CMS will require OCM participants to achieve six practice transformation improvements. Depending on a practice’s current infrastructure, achieving these may come at a significant cost. CMS has indicated that in addition to the $160 per beneficiary per month payments built into the model, providers can expect to receive the following to help cover practice transformation costs:
- enhanced payments from other payers
- continued billing for non-OCM patients for chronic care management, transitional care management.
CMS has clarified that the first practice requirement, 24/7 clinician access, may be met by provider patient access to nurses and non-physician practitioners as well as physicians. Additionally, these providers may access patient records remotely. For the patient navigation requirement, CMS has clarified practices can use existing staff to fulfill this requirement.
Webinar: "Should You Participate & How to Prepare" with Kavita Patel, MD, MSHS
On Tuesday, April 28, Kavita Patel, MD, MSHS, managing director, the Brookings Institution, presented a webinar on the CMMI Oncology Care Model that provides a strategic perspective on questions to consider before submitting your Letter of Intent (LOI).
This webinar was supported by the Oncology State Society Network (OSSN) State Society Education Series.
Click here to watch this webinar on demand.
ASCO–ACCC Webinar on Completing the CMMI Oncology Care Model Application
On June 4, 2015, the American Society of Clinical Oncology (ASCO) and the Association of Community Cancer Centers (ACCC) hosted "The OCM Application: Getting it Done," a tutorial webinar on the application process for the CMMI's Oncology Care Model. The webinar, which was open to practices that have submitted an LOI to CMS, focused on completing the OCM application package by the June 30, 2015, deadline. (Note: On June 4, CMS extended the OCM application deadline from June 18 to June 30, 2015.)
On June 10, practices that submitted an LOI were sent information on how to access a recording of the webinar and the webinar slides. Please contact us at email@example.com, if you have questions.