Can a new payment model improve cancer care? It’s going to try

An oncology care delivery model being tested by HHS attracted the participation of 196 physician group practices and 17 health insurance companies. The Oncology Care Model, which includes more than 3,200 oncologists and will cover approximately 155,000 Medicare beneficiaries nationwide, will support and encourage higher quality and more coordinated cancer care for five years, beginning July 1, 2016.

Cancer costs to federal health care programs

The CMS Innovation Center develops and tests novel health care payment and delivery models with the goal of providing more efficient, more effective care at a higher quality while keeping costs to the Medicare program at the same level or lower. Each year, more than 1.6 million Americans receive a new diagnosis of cancer, and approximately 600,000 Americans die from cancer. The National Institutes of Health projects that medical expenditures for cancer in 2020, a significant portion of which will go to individuals older than 65 who are Medicare beneficiaries, will cost at least $158 billion.

Oncology Care Model

Under the Oncology Care Model, participating practices will emphasize person-centered care while following nationally recognized clinical guidelines to provide treatment to beneficiaries undergoing chemotherapy. Beneficiaries will receive timely, coordinated treatment with enhanced services, such as:

  • coordinating appointments with providers within and outside the oncology practice to ensure timely delivery of diagnostic and treatment services;
  • providing 24/7 access to care when needed;
  • arranging for diagnostic scans and follow up with other members of the medical team such as surgeons, radiation oncologists, and other specialists that support the beneficiary through his or her cancer treatment;
  • making sure that data from scans, blood test results, and other tests are received in advance of patient appointments so that patients do not need to schedule additional visits; and
  • providing access to additional patient resources, such as emotional support groups, pain management services, and clinical trials.

Model payment

The Oncology Care Model includes 17 commercial payers, in alignment with Medicare. The goal is to create broader incentives for care transformation at the physician practice level and across a broader patient population. Participating payers have the flexibility to design their own payment incentives to support their beneficiaries, while aligning with the Innovation Center’s goals for care improvement and efficiency.

Participating practices will be paid under a two-part system that creates incentives to improve the quality of care and furnish enhanced services for beneficiaries who undergo chemotherapy treatment for a cancer diagnosis. The payment forms include a per-beneficiary Monthly Enhanced Oncology Services (MEOS) payment for the duration of the episode and the potential for a performance-based payment for episodes of chemotherapy care. The $160 MEOS payment assists participating practices in effectively managing and coordinating care for oncology patients during episodes of care, while the potential for performance-based payment incentivizes practices to lower the total cost of care and improve care for beneficiaries during treatment episodes.

High participation rates

HHS expected half as many participants as the Oncology Care Model received, with CMS principal deputy administrator and chief medical officer Patrick Conway, M.D., saying that the agency is “thrilled.” Conway explained the high participation rates, saying “oncology physicians recognize the importance of this new performance-based, episode-based payment approach to cancer care.”