Unlocking success: Full year quality and utilization metrics of payer-provider OMH partnership.

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41 Background: For more than a decade, CMS and commercial payers have sought to engage provider organizations in value-based cancer care payment models (VBPMs). Success of VBPMs requires payer/provider alignment on quality/utilization measures indicative of high-value care and the efficiency of data exchange between providers and payers. The following describes several key metrics from the first full year 2022 of the Tennessee Oncology (TO) and BlueCross BlueShield of Tennessee (BCBST) Oncology Medical Home (OMH) partnership. Methods: TO and BCBST implemented reporting methodologies for a combination of practice-reported quality and utilization measures and payer claims-based measures: Patient experience, Pathway adherence, Distress screening / interventions, Admissions/1000 patients, ED visits/1000 patients, Imaging utilization, and Observation stays. Bi-weekly meetings between practice and payer were necessary to review quality/utilization measure reporting, coordinate overall program administration, and monitor member attribution for care management and performance-based payments. Results: TO/BCBST co-developed a VBPM that included bi-directional reporting of practice-reported quality and utilization measures and payer claims-based measures. Technical challenges in data sharing and reporting occurred frequently and required regular troubleshooting. Questions regarding trends in observed data arose frequently for both TO and BCBST and required regular discussions between clinical/operational leaders of payer and practice (Table). Conclusions: These data suggest that payers and community oncology practices can co-develop value-based payment models that yield transparency in quality and utilization data reporting, and observed differences in performance and cost-efficiency among different practices in a market. Payers can gain increased transparency in quality and cost-efficiency of cancer care for their members. Practices can leverage care management payments and performance-based payments to support care delivery and quality/utilization data reporting improvements. Provider and payer capabilities to execute transparent QM/UM reporting is a major challenge in implementing OMH programs. 2022 OMH results. Measure % higher or lower than benchmarks Admissions /k -7.0 ED visit /k -8.4 Imaging utilization + 9.4 Observation stays -10.0 Patient experience NA Pathway adherence NA Distress screening / interventions NA Hospice reporting NA NA = not applicable, no benchmark data available/measured; /k = per 1000 patients; negative = lower than benchmarks; positive = higher than benchmarks.