OCM Performance Period 1 Results Revealed an Unwelcome Surprise

In February, practices participating in the Oncology Care Model (OCM) program received their Performance Period 1 (PP1) initial reconciliation reports, which summarized actual expenditures from July 1, 2016 through December 31, 2016, and determined whether total episodic costs of care were higher or lower than CMS targets. For many practices, this was the first time they received visibility into their overall performance under the OCM, including savings achieved, aggregate quality score, and effectiveness of identifying eligible patients.

Not surprisingly, performance-based payments were relatively rare. That said, even though all OCM practices opted for the single-sided risk model to protect their bottom lines, many did not anticipate the extent to which CMS would recoup MEOS payments that – according to CMS calculations – were paid in error.

MEOS Recoupment: The “Other” Downside Risk

While some recoupment requests were straightforward – such as duplicate MEOS payments in the same calendar month – others were not. Most notably, practices have been asked to return MEOS payments for beneficiaries not attributed to their practice or if the patient was deemed to have not had a PP1 episode. For some OCM practices, these recoupments were equivalent to 30% or more of total MEOS payments – a major blow.
Practices were given until this week – April 18th – to contest CMS’ findings. They were expected to provide a comprehensive analysis – down to the patient level – challenging CMS’ calculations. The most impactful disconnects with respect to attribution were from the following two categories:

  • Beneficiary not attributed to the practice: Practices needed to demonstrate why they should be attributed specific patients for whom the practice provided cancer treatment and advanced services, even if the patient saw other clinicians (eg. PCP, cardiologist, etc.) more often.
  • Patient did not have a PP1 episode: Practices were required to justify why they believe specific beneficiaries met the qualifying criteria, but most are still struggling to understand CMS’ eligibility logic.

Lack of Holistic Patient Data a Top Concern for OCM Practices

What were the greatest challenges OCM practices faced with respect to correctly identifying eligible beneficiaries? Attribution varied significantly by cancer type and the number of patient co-morbidities. For example, patients with cancer types like hormone-receptor-positive breast cancer who had few oncology visits were more often attributed to other specialists or their primary care physician, even when their oncology medications and oncology-specific treatment was delivered by their oncologist. Additionally, patients with more comorbidities had a higher likelihood of seeing other physicians, resulting in the oncology practice not having the plurality of visits and therefore not being attributed the beneficiary.

Lack of data, resulting in reduced visibility into the complete episode of care or across all care settings, significantly hindered practices’ ability to accurately and proactively identify eligible beneficiaries.

  • Access to all patient data: Practices found it particularly difficult to understand and mimic CMS’ logic for eligibility and attribution – especially in advance – without access to all necessary patient data, including information about services rendered by other providers and prescription fill dates for oral agents.
  • Plurality of E/M visits: If a patient saw their PCP more times than their oncologists, irrespective of the advanced services (eg. care navigation) provided by the oncologists, the episode was not attributed to the oncologist. Without a holistic view of patient data – across all care settings – validating the number of visits to other clinicians is close to impossible.
  • Lack of real-time performance metrics: There is a significant time delay between actual Performance Period and official CMS findings. Practices must wait two calendar quarters after each performance period has ended to receive their initial attribution reports.

A Data-Driven Approach to Contestation

Without proficiency in analyzing CMS claims data, contesting has proven to be very onerous for practices. To optimize your practice’s efforts, we recommend comparing the steps you’ve taken, or plan to take, with some early best practices:

  1. Compare MEOS Recoupment reports against calculated episode identification and attribution to identify significant outliers and trends.
  2. Target only those patients or claims for which your practice can justify contesting, focusing on the categories that have the biggest impact on the practice’s bottom line.
  3. Be sure to include supporting detail that your practice can use for the contestation to demonstrate why the CMS results are believed to be inaccurate.
  4. Until your practice has developed a high-level of precision for identifying eligible patients, consider holding some MEOS payment in reserve to cover future recoupments.

To minimize future MEOS recoupments and optimize performance under the OCM, practices are also investing in better data integration and analytics that enable rules-based identification of eligible patients. See how Integra Connect helps its OCM practice clients with a suite of advanced population health analytics solutions.