OCM Performance Period 2 Results: Practices Still Addressing Performance Gaps and Challenges with CMS Logic

November 28, 2018

Since this article was originally published, Integra Connect supported OCM-participating oncology providers, practices, and payers for five years and across more than 200,000 patient episodes, representing one of the largest networks of OCM lives. Read Integra Connect’s statement on the Enhancing Oncology Model.

Earlier this year, Oncology Care Model (OCM) practices received their first set of performance results for Performance Period 1, measuring the period of time with episodes between July 1st of 2016 and January 1st of 2017. These included the PP1 Initial Reconciliation Report and the PP1 MEOS Recoupment Report. These early assessments indicated that many practices were still struggling to generate savings, as well as understand CMS’ beneficiary eligibility and attribution logic. At the end of August, the Centers for Medicare and Medicaid Services (CMS) released its second set of Oncology Care Model (OCM) performance results, which included a revision of PP1 results, as well as the release of performance results for Performance Period 2 (PP2) covering episodes between January 2nd and July 1st of 2017.

The August release revealed that, while OCM practices seem to be closing the cost gap, they are not out of the woods yet.

  • The PP2 Initial Reconciliation Report – which measures the delta between actual expenditures per qualifying six-month episode of cancer care and a CMS target price – indicated an average 46% performance improvement. A deeper dive, however, revealed that this was more often correlated with trend factor or novel therapy adjustments that resulted in a target price increase rather than episodic cost reductions.
  • Monthly-Enhanced Oncology Services (MEOS) attributions remain a top concern, doubling in PP2 to as much as 60% of MEOS payments, on average. The same issues that plagued practices in PP1 continued in PP2, including lack of holistic patient data across care settings; inability to track the plurality of E/M visits; and the absence of real-time reporting to determine whether patients met the qualifying criteria.
  • The impact of claims runout on PP1 – as revealed in the PP1 True Up Reconciliation Report – dealt another major blow to some practices. For those few practices who received a performance bonus in PP1, any performance bonus paid out would be recouped if the PP1 True Up analysis reduced or eliminated the savings estimated by the PP1 Initial Reconciliation Report.

As practices continue to digest their latest performance results, they have expressed growing concerns about the OCM program design. While the statistical models have improved, without real-time access to or proficiency in analyzing CMS claims data, the MEOS attribution logic and target price estimates continue to elude practices.

Practices Are Doubling Down on Existing Transformation Efforts to Optimize Performance

While OCM PP2 results were mixed, practices remain committed to value-based care in general, and to the OCM in particular.  They therefore continue to drive ongoing efforts to optimize quality while minimizing total costs of care. These include:

  • Care Pathway Adherence: Leveraging evidence-based pathways to improve survival rates and reduce cost, especially for high-volume cancer types with high variance in costs.
  • Reducing ER Visits and Hospitalizations:Leveraging risk prediction models to proactively identify and engage high-risk patients; extending office hours; conducting symptom and triage management; and more.
  • Managing End-of-Life Resources: Reconsidering aggressive therapy in advanced stages of illness and instead referring patients to palliative care, hospice, or in-home care resources.

With the Help of Integra Connect, Practices Are Also Targeting New Focus Areas

The OCM PP2 performance results revealed two new, unforeseen outcomes as a result of reducing adverse events: Under-valued target prices for new patients due to little or no co-morbidity documentation and more scrutiny of novel therapies. To proactively address these challenges, Integra Connect has delivered personalized reporting tools as part of its Intelligence advanced analytics solution to facilitate better documentation and value-based treatment decisions:

  • More consistent, comprehensive documentation of co-morbidities: With fewer patients going to the ER, oncologists are now accountable for ensuring sufficient co-morbidity documentation. The Integra Connect Documentation Gap Dashboard identifies high-priority co-morbid conditions, such as diabetes, cardiac disease and COPD, then alerts oncologists and their teams to both ensure comprehensive documentation as well as facilitate the appropriate referrals.
  • Utilization of novel therapies based on value, not just cost: To continue driving meaningful savings under the OCM program, practices will need make treatment decisions based on overall value: quality of life, clinical outcomes, and total cost of care. Integra Connect’s Clinical Analytics Suite delivers data-driven insights into treatment patterns and pathways compliance, empowering practices to optimize utilization of novel therapies in alignment with evidence-based pathways while managing total cost of care per episode.

To continue participating in the OCM program, practices will be expected to generate savings within at least one performance period through PP4. See how Integra Connect supports OCM practices with a suite fully-integrated, cloud-based technologies and services.