Impact of Oncology Care Model (OCM) on episode costs and performance revenues: Considerations for oncology practices.

Abstract

102 Background: The OCM is focused on providing high-quality, cost-efficient oncology care in Medicare. The episode payment approach introduces performance-based payments (PBPs) alongside traditional fee-for-service reimbursements. There is not yet a clear picture of the impact of the OCMs implementation on oncology practices. Methods: Using the Medicare Standard Analytic Files (5% sample) Part A and B claims, this study replicates the OCM benchmarking payment methodology. OCM episodes were triggered by qualifying Part B cancer therapies administered in an outpatient setting; all Part A and B costs that occurred in the following 6-months were included in episode costs. Claims for the baseline period (July 2012 – June 2015) were used to calculate actual episode costs, and predicted episode costs were used for benchmarks. Claims were also used to estimate OCM claims-based quality measure scores. Quality measure scores determined a practice’s performance multiplier, which is part of the PBP calculation. Results: The average ratio of OCM actual-to-predicted costs varied by tumor type. Of the 21 tumor types, 12 underpredicted costs and 7 overpredicted costs. The underpredicted tumors accounted for 43% of OCM episodes, and the overpredicted account for 51%. Central nervous system tumors and malignant melanoma were the most underpredicted cost ratios at 1.29 and 1.27, respectively. Claims-based quality measures also varied by tumor type. Aggregate scores for the three claims-based measures were < 50% for 18 tumors (65% of episodes) and ≥50% for 3 tumors (35% of episodes). Practices treating patients with tumors that are underpredicted on cost and/or score low on quality measures will have greater difficulty achieving PBPs. Conclusions: This analysis suggests that the ability of a participant to succeed in the OCM will vary depending on the types of cancers treated at the practice. Both savings and quality, as measured by OCM, will vary across cancers. For some cancers, achieving an ‘average’ cost and an ‘average’ quality score could result in below-average performance for the practice. Understanding these dynamics are critical to understanding the potential impact of the OCM at the practice level.