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Navigating the Oncology Care Model
Care of the cancer patient is complex and expensive. During 2001-2011, medical spending to treat cancer increased from $56.8 billion to $88.3 billion in the United States. During this time, ambulatory expenditures for care and treatment increased while inpatient hospital expenditures decreased.1,2 Treatments for cancer have advanced, but costs do not correlate with outcomes. Advanced payment models aimed at ensuring high quality while lowering costs may be the vehicle to help mitigate the financial burden of cancer treatment on patients and society at large.
Oncology Care Model
The Center for Medicare and Medicaid Innovation designed the Oncology Care Model (OCM), which allows practices and payers in the United States to partner with the Centers for Medicare & Medicaid Services. The goal of the OCM is to provide high quality, highly coordinated cancer care at the same or lower cost. Practice partnerships with the CMS involve payment arrangements that include financial and performance accountability for episodes of cancer care surrounding chemotherapy delivery to patients.3
Practices that have been selected by the CMS have attested to providing a number of enhanced services from 24/7 patient access to an appropriate clinician who can access medical records to having a documented care plan for every patient.4
Payment methodology
An episode of care is defined as a 6-month period that starts at the time of chemotherapy administration. In addition to the standard fee-for-service payment, practices have the ability to earn two other types of payments during an oncology episode.
The per-beneficiary Monthly Enhanced Oncology Services payment is $960 for the entire episode but is paid to practices at $160 per month.
Practices have the potential to earn additional performance-based payments (PBP) based on the difference in cost between the projected and actual cost of the episode. The PBP also incorporates performance on quality metrics, based on Medicare claims and other information submitted by the practice. For example, claims-based measures include hospital, emergency department (ED), and hospice utilization.
To participate in the OCM, practices must choose either a one-sided or two-sided risk model. In the one-sided risk model, practices take on no downside risk but need to achieve a greater reduction in expenditures (4% below the benchmark price). In the two-side risk model, practices need only to reduce expenditures by 2.75% below the benchmark price. But if they fail to meet their savings goals, they must pay the difference to the CMS. The recoupment is capped at 20% of the benchmark amount.
Feedback reports
The CMS sends quarterly feedback reports that contain information on practice demographics, outcomes, expenditures, chemotherapy use, and patient satisfaction. The outcomes include the mortality rate for Medicare beneficiaries treated at the practice, compared with other practices nationally. In addition, the reports include end-of-life metrics and patient satisfaction, as well as details of expenditures on drugs, hospital use, imaging and laboratory services, and a description of chemotherapy usage.
These reports can be a helpful tool for measuring your own use of services, as well as benchmarking it against national figures.
Practice modifications
According to CMS feedback reports, the cost of care per beneficiary per month has increased across all practices since the inception of the OCM. However, there are practices that have been successful in reducing cost of care without negatively affecting mortality.
Drugs, hospital, and ED visits, along with imaging and laboratory evaluation, account for 75% of the cost. Some strategies to reduce expenditure involve targeting those areas.
Consider prescribing drugs conservatively without affecting outcomes. For instance, bisphosphonates for bone metastasis can be given every 12 weeks instead of 4 weeks.5 Similarly, adjuvant chemotherapy can be given for 3 months, instead of 6 months in appropriate stage 3 colon cancer patients.6
Another potential opportunity for savings is the judicious use of pertuzumab in early-stage breast cancer patients.7 These are all evidence-based recommendations with potential for cost savings. Clinical pathways can aid in this process, but physician buy-in is imperative.
In terms of imaging, avoid PET scans when they will not affect your clinical decision making, avoid staging scans in early-stage breast and prostate cancer patients, and avoid surveillance scans among early-stage breast cancer and lymphoma patients. The Choosing Wisely campaign can help guide some of these decisions.8
Another area where good care meets cost effective care is in the early engagement of palliative care. Several studies have shown that early involvement of palliative care improves survival and quality of life.9,10 Palliative care involvement also decreases the emotional burden for patients and oncologists. Appropriate symptom control, particularly of pain, decreases hospitalizations during treatment.
Investing in a robust supportive care team – financial advocates, social work, nutrition, behavioral health, as well as various community services – can help reduce the financial, physical, and emotional distress levels for patients. All of these services ultimately lead to reduced hospitalizations.11 The Monthly Enhanced Oncology Services payment can be put toward these expenses.
Care teams working at the highest level of competence and license can also save time and money. Consider using registered nurses to implement triage pathways to assess side effects and symptom management, or using nurse practitioners, registered nurses, and physician assistants for same-day appointments and to assess symptoms rather than referring patients to the emergency department.
Avoid the ED and hospitalizations by using the infusion center to provide hydration and blood transfusions in a timely fashion.
Telemedicine can be used for symptom management as well as leveraging supportive care services.
Cost for cancer care is very difficult to sustain. The OCM provides early insights into expenditures, challenges, and opportunities. Practices should use this information to build infrastructure and provide high quality, cost-effective care. Value-based cancer care should be the overarching goal for oncology practices and health care organizations.
Dr. Mahesh is the director of hematology-oncology and program director of the Oncology Care Model at Summa Health in Akron, Ohio.
References
1. Siegel RL et al. Cancer statistics, 2018. CA Cancer J Clin. 2018 Jan;68(1):7-30.
2. Medical Expenditure Panel Survey, Statistical Brief #443. 2014 Jun.
3. CMS: Oncology Care Model.
4. CMS: OCM Frequently Asked Questions.
5. Himelstein AL et al. Effect of longer-interval vs. standard dosing of zoledronic acid on skeletal events in patients with bone metastases. JAMA. 2017 Jan 3;317(1):48-58.
6. Grothey A et al. Duration of adjuvant chemotherapy for stage III colon cancer. N Engl J Med. 2018;378(13):1177-88.
7. Von Minckwitz G et al. Adjuvant pertuzumab and trastuzumab in early HER2-positive breast cancer. N Engl J Med. 2017;377(2):122-31.
8. American Society of Clinical Oncology: Ten Things Physician and Patients Should Question.
9. Temel JS et al. Early palliative care for patients with metastatic non–small cell lung cancer. N Engl J Med. 2010;363(8):733-42.
10. Blayney DW et al. Critical lessons from high-value oncology practices. JAMA Oncol. 2018 Feb 1;4(2):164-71.
11. Sherman DE. Transforming practices through the oncology care model: financial toxicity and counseling. J Oncol Pract. 2017 Aug;13(8):519-22.
Care of the cancer patient is complex and expensive. During 2001-2011, medical spending to treat cancer increased from $56.8 billion to $88.3 billion in the United States. During this time, ambulatory expenditures for care and treatment increased while inpatient hospital expenditures decreased.1,2 Treatments for cancer have advanced, but costs do not correlate with outcomes. Advanced payment models aimed at ensuring high quality while lowering costs may be the vehicle to help mitigate the financial burden of cancer treatment on patients and society at large.
Oncology Care Model
The Center for Medicare and Medicaid Innovation designed the Oncology Care Model (OCM), which allows practices and payers in the United States to partner with the Centers for Medicare & Medicaid Services. The goal of the OCM is to provide high quality, highly coordinated cancer care at the same or lower cost. Practice partnerships with the CMS involve payment arrangements that include financial and performance accountability for episodes of cancer care surrounding chemotherapy delivery to patients.3
Practices that have been selected by the CMS have attested to providing a number of enhanced services from 24/7 patient access to an appropriate clinician who can access medical records to having a documented care plan for every patient.4
Payment methodology
An episode of care is defined as a 6-month period that starts at the time of chemotherapy administration. In addition to the standard fee-for-service payment, practices have the ability to earn two other types of payments during an oncology episode.
The per-beneficiary Monthly Enhanced Oncology Services payment is $960 for the entire episode but is paid to practices at $160 per month.
Practices have the potential to earn additional performance-based payments (PBP) based on the difference in cost between the projected and actual cost of the episode. The PBP also incorporates performance on quality metrics, based on Medicare claims and other information submitted by the practice. For example, claims-based measures include hospital, emergency department (ED), and hospice utilization.
To participate in the OCM, practices must choose either a one-sided or two-sided risk model. In the one-sided risk model, practices take on no downside risk but need to achieve a greater reduction in expenditures (4% below the benchmark price). In the two-side risk model, practices need only to reduce expenditures by 2.75% below the benchmark price. But if they fail to meet their savings goals, they must pay the difference to the CMS. The recoupment is capped at 20% of the benchmark amount.
Feedback reports
The CMS sends quarterly feedback reports that contain information on practice demographics, outcomes, expenditures, chemotherapy use, and patient satisfaction. The outcomes include the mortality rate for Medicare beneficiaries treated at the practice, compared with other practices nationally. In addition, the reports include end-of-life metrics and patient satisfaction, as well as details of expenditures on drugs, hospital use, imaging and laboratory services, and a description of chemotherapy usage.
These reports can be a helpful tool for measuring your own use of services, as well as benchmarking it against national figures.
Practice modifications
According to CMS feedback reports, the cost of care per beneficiary per month has increased across all practices since the inception of the OCM. However, there are practices that have been successful in reducing cost of care without negatively affecting mortality.
Drugs, hospital, and ED visits, along with imaging and laboratory evaluation, account for 75% of the cost. Some strategies to reduce expenditure involve targeting those areas.
Consider prescribing drugs conservatively without affecting outcomes. For instance, bisphosphonates for bone metastasis can be given every 12 weeks instead of 4 weeks.5 Similarly, adjuvant chemotherapy can be given for 3 months, instead of 6 months in appropriate stage 3 colon cancer patients.6
Another potential opportunity for savings is the judicious use of pertuzumab in early-stage breast cancer patients.7 These are all evidence-based recommendations with potential for cost savings. Clinical pathways can aid in this process, but physician buy-in is imperative.
In terms of imaging, avoid PET scans when they will not affect your clinical decision making, avoid staging scans in early-stage breast and prostate cancer patients, and avoid surveillance scans among early-stage breast cancer and lymphoma patients. The Choosing Wisely campaign can help guide some of these decisions.8
Another area where good care meets cost effective care is in the early engagement of palliative care. Several studies have shown that early involvement of palliative care improves survival and quality of life.9,10 Palliative care involvement also decreases the emotional burden for patients and oncologists. Appropriate symptom control, particularly of pain, decreases hospitalizations during treatment.
Investing in a robust supportive care team – financial advocates, social work, nutrition, behavioral health, as well as various community services – can help reduce the financial, physical, and emotional distress levels for patients. All of these services ultimately lead to reduced hospitalizations.11 The Monthly Enhanced Oncology Services payment can be put toward these expenses.
Care teams working at the highest level of competence and license can also save time and money. Consider using registered nurses to implement triage pathways to assess side effects and symptom management, or using nurse practitioners, registered nurses, and physician assistants for same-day appointments and to assess symptoms rather than referring patients to the emergency department.
Avoid the ED and hospitalizations by using the infusion center to provide hydration and blood transfusions in a timely fashion.
Telemedicine can be used for symptom management as well as leveraging supportive care services.
Cost for cancer care is very difficult to sustain. The OCM provides early insights into expenditures, challenges, and opportunities. Practices should use this information to build infrastructure and provide high quality, cost-effective care. Value-based cancer care should be the overarching goal for oncology practices and health care organizations.
Dr. Mahesh is the director of hematology-oncology and program director of the Oncology Care Model at Summa Health in Akron, Ohio.
References
1. Siegel RL et al. Cancer statistics, 2018. CA Cancer J Clin. 2018 Jan;68(1):7-30.
2. Medical Expenditure Panel Survey, Statistical Brief #443. 2014 Jun.
3. CMS: Oncology Care Model.
4. CMS: OCM Frequently Asked Questions.
5. Himelstein AL et al. Effect of longer-interval vs. standard dosing of zoledronic acid on skeletal events in patients with bone metastases. JAMA. 2017 Jan 3;317(1):48-58.
6. Grothey A et al. Duration of adjuvant chemotherapy for stage III colon cancer. N Engl J Med. 2018;378(13):1177-88.
7. Von Minckwitz G et al. Adjuvant pertuzumab and trastuzumab in early HER2-positive breast cancer. N Engl J Med. 2017;377(2):122-31.
8. American Society of Clinical Oncology: Ten Things Physician and Patients Should Question.
9. Temel JS et al. Early palliative care for patients with metastatic non–small cell lung cancer. N Engl J Med. 2010;363(8):733-42.
10. Blayney DW et al. Critical lessons from high-value oncology practices. JAMA Oncol. 2018 Feb 1;4(2):164-71.
11. Sherman DE. Transforming practices through the oncology care model: financial toxicity and counseling. J Oncol Pract. 2017 Aug;13(8):519-22.
Care of the cancer patient is complex and expensive. During 2001-2011, medical spending to treat cancer increased from $56.8 billion to $88.3 billion in the United States. During this time, ambulatory expenditures for care and treatment increased while inpatient hospital expenditures decreased.1,2 Treatments for cancer have advanced, but costs do not correlate with outcomes. Advanced payment models aimed at ensuring high quality while lowering costs may be the vehicle to help mitigate the financial burden of cancer treatment on patients and society at large.
Oncology Care Model
The Center for Medicare and Medicaid Innovation designed the Oncology Care Model (OCM), which allows practices and payers in the United States to partner with the Centers for Medicare & Medicaid Services. The goal of the OCM is to provide high quality, highly coordinated cancer care at the same or lower cost. Practice partnerships with the CMS involve payment arrangements that include financial and performance accountability for episodes of cancer care surrounding chemotherapy delivery to patients.3
Practices that have been selected by the CMS have attested to providing a number of enhanced services from 24/7 patient access to an appropriate clinician who can access medical records to having a documented care plan for every patient.4
Payment methodology
An episode of care is defined as a 6-month period that starts at the time of chemotherapy administration. In addition to the standard fee-for-service payment, practices have the ability to earn two other types of payments during an oncology episode.
The per-beneficiary Monthly Enhanced Oncology Services payment is $960 for the entire episode but is paid to practices at $160 per month.
Practices have the potential to earn additional performance-based payments (PBP) based on the difference in cost between the projected and actual cost of the episode. The PBP also incorporates performance on quality metrics, based on Medicare claims and other information submitted by the practice. For example, claims-based measures include hospital, emergency department (ED), and hospice utilization.
To participate in the OCM, practices must choose either a one-sided or two-sided risk model. In the one-sided risk model, practices take on no downside risk but need to achieve a greater reduction in expenditures (4% below the benchmark price). In the two-side risk model, practices need only to reduce expenditures by 2.75% below the benchmark price. But if they fail to meet their savings goals, they must pay the difference to the CMS. The recoupment is capped at 20% of the benchmark amount.
Feedback reports
The CMS sends quarterly feedback reports that contain information on practice demographics, outcomes, expenditures, chemotherapy use, and patient satisfaction. The outcomes include the mortality rate for Medicare beneficiaries treated at the practice, compared with other practices nationally. In addition, the reports include end-of-life metrics and patient satisfaction, as well as details of expenditures on drugs, hospital use, imaging and laboratory services, and a description of chemotherapy usage.
These reports can be a helpful tool for measuring your own use of services, as well as benchmarking it against national figures.
Practice modifications
According to CMS feedback reports, the cost of care per beneficiary per month has increased across all practices since the inception of the OCM. However, there are practices that have been successful in reducing cost of care without negatively affecting mortality.
Drugs, hospital, and ED visits, along with imaging and laboratory evaluation, account for 75% of the cost. Some strategies to reduce expenditure involve targeting those areas.
Consider prescribing drugs conservatively without affecting outcomes. For instance, bisphosphonates for bone metastasis can be given every 12 weeks instead of 4 weeks.5 Similarly, adjuvant chemotherapy can be given for 3 months, instead of 6 months in appropriate stage 3 colon cancer patients.6
Another potential opportunity for savings is the judicious use of pertuzumab in early-stage breast cancer patients.7 These are all evidence-based recommendations with potential for cost savings. Clinical pathways can aid in this process, but physician buy-in is imperative.
In terms of imaging, avoid PET scans when they will not affect your clinical decision making, avoid staging scans in early-stage breast and prostate cancer patients, and avoid surveillance scans among early-stage breast cancer and lymphoma patients. The Choosing Wisely campaign can help guide some of these decisions.8
Another area where good care meets cost effective care is in the early engagement of palliative care. Several studies have shown that early involvement of palliative care improves survival and quality of life.9,10 Palliative care involvement also decreases the emotional burden for patients and oncologists. Appropriate symptom control, particularly of pain, decreases hospitalizations during treatment.
Investing in a robust supportive care team – financial advocates, social work, nutrition, behavioral health, as well as various community services – can help reduce the financial, physical, and emotional distress levels for patients. All of these services ultimately lead to reduced hospitalizations.11 The Monthly Enhanced Oncology Services payment can be put toward these expenses.
Care teams working at the highest level of competence and license can also save time and money. Consider using registered nurses to implement triage pathways to assess side effects and symptom management, or using nurse practitioners, registered nurses, and physician assistants for same-day appointments and to assess symptoms rather than referring patients to the emergency department.
Avoid the ED and hospitalizations by using the infusion center to provide hydration and blood transfusions in a timely fashion.
Telemedicine can be used for symptom management as well as leveraging supportive care services.
Cost for cancer care is very difficult to sustain. The OCM provides early insights into expenditures, challenges, and opportunities. Practices should use this information to build infrastructure and provide high quality, cost-effective care. Value-based cancer care should be the overarching goal for oncology practices and health care organizations.
Dr. Mahesh is the director of hematology-oncology and program director of the Oncology Care Model at Summa Health in Akron, Ohio.
References
1. Siegel RL et al. Cancer statistics, 2018. CA Cancer J Clin. 2018 Jan;68(1):7-30.
2. Medical Expenditure Panel Survey, Statistical Brief #443. 2014 Jun.
3. CMS: Oncology Care Model.
4. CMS: OCM Frequently Asked Questions.
5. Himelstein AL et al. Effect of longer-interval vs. standard dosing of zoledronic acid on skeletal events in patients with bone metastases. JAMA. 2017 Jan 3;317(1):48-58.
6. Grothey A et al. Duration of adjuvant chemotherapy for stage III colon cancer. N Engl J Med. 2018;378(13):1177-88.
7. Von Minckwitz G et al. Adjuvant pertuzumab and trastuzumab in early HER2-positive breast cancer. N Engl J Med. 2017;377(2):122-31.
8. American Society of Clinical Oncology: Ten Things Physician and Patients Should Question.
9. Temel JS et al. Early palliative care for patients with metastatic non–small cell lung cancer. N Engl J Med. 2010;363(8):733-42.
10. Blayney DW et al. Critical lessons from high-value oncology practices. JAMA Oncol. 2018 Feb 1;4(2):164-71.
11. Sherman DE. Transforming practices through the oncology care model: financial toxicity and counseling. J Oncol Pract. 2017 Aug;13(8):519-22.