The Center for Medicare & Medicaid Innovation:
Preliminary design for an oncology-focused model
Introduction to Specialty Practitioner Payment Models
The Center for Medicare & Medicaid Innovation (Innovation Center) has a growing portfolio testing various payment and
service delivery models. These models aim to achieve better care for patients, to improve health in our communities,
and to lower costs through improvement of our health care system. The Innovation Center is exploring specialty
practitioner payment models that focus on services that are typically furnished by specialists1. With input from
stakeholders, the Innovation Center has identified cancer care, particularly chemotherapy treatment, as an area where
health care and care coordination can be improved while reducing spending. The Innovation Center is developing an
oncology payment model, currently referred to as the Oncology Care Model (OCM), to test the effect of better care
coordination, improved access to practitioners, and appropriate clinical care on improving health outcomes at a lower
cost.
This design paper is intended to share the current thinking regarding a potential oncology episode-based payment
model test. Aspects of the model are subject to change. If the Innovation Center decides to implement OCM, the
Innovation Center will publish the final model with additional detail regarding participation in the model on the
Innovation Center website.
Overview of OCM
The goal of OCM would be to utilize appropriately aligned financial incentives, including performance-based payments,
to improve care coordination, appropriateness of care, and access for beneficiaries undergoing chemotherapy, resulting
in improved health outcomes, higher quality care, and lower expenditures. Financial incentives for appropriate care
should reduce health care expenditures as participating practices collaboratively and comprehensively address the
complex care needs of the beneficiary population receiving chemotherapy treatment, while decreasing the use of
services that do not improve health outcomes.
OCM would target chemotherapy treatment and the spectrum of care provided to a patient during a 6-month episode
following the start of chemotherapy treatment. Participants would be physician practices that furnish chemotherapy
treatment, and would be expected to engage in practice transformation to improve the quality of care they deliver. This
transformation would be driven by the requirements practices must fulfill in order to participate in OCM, including:
 Employ one or more designated patient navigator/care coordinators;
 Document a care plan that contains the 13 components in the Institute of Medicine Care Management Plan
outlined in the Institute of medicine report, “Delivering High-Quality Cancer Care: Charting a New Course for a
System in Crisis”;2
 Provide and attest to 24 hours a day, 7 days a week patient access to an appropriate clinician who has real-time
access to practice’s medical records;
1
http://innovation.cms.gov/initiatives/Specialty-Practitioner/
Institute of Medicine Report. Levit L, Balogh E, Nass S and Ganz P, ed. Delivering High-Quality Cancer Care: Charting a New Course
for a System in Crisis. 2013. The full list of components is in Appendix B.
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The Center for Medicare & Medicaid Innovation:
Preliminary design for an oncology-focused model
 Utilize data for continuous quality improvement; and
 Use an ONC-certified EHR and attest to Stage 2 of meaningful use by the end of the fourth model performance
year.
A number of quality measures would be used to monitor and evaluate the model and to provide continuous feedback to
practices throughout the model. In addition, some measures would be used to adjust the performance-based payments.
A preliminary list of measures is in Appendix A.
Multipayer Model
OCM would be a multi-payer model that includes Medicare fee-for-service (OCM-FFS) and other payers (OCM-OP)
working in tandem to leverage the opportunity to transform care for oncology patients across the population. Medicare
beneficiaries represent approximately 50 percent of oncology patients. This is a significant number, but engaging other
payers would allow OCM to drive comprehensive care redesign at the practice level and improve cancer care for more
patient populations. Other payers beyond Medicare FFS would be able to participate in OCM by entering into a
Memorandum of Understanding (MOU) with the Innovation Center. There may be differences between OCM-FFS and
OCM-OP in certain areas, such as selection of performance-based payment measures. However, the approach to
practice transformation would be consistent across OCM.
Application Process
The Innovation Center would require Letters of Intents (LOIs) from payers and practices, which (with permission) would
be posted publicly to facilitate cooperation between payers and practices prior to model implementation. Payers and
practices would separately apply to participate in OCM. During the participant selection process, the Innovation Center
would prioritize physician practices that would be participating in OCM with Medicare FFS and other payers.
Target Population and Geographic Scope
Eligible beneficiaries for OCM-FFS would include beneficiaries who are eligible for Medicare Part A and enrolled in
Medicare Part B; have Medicare FFS as their primary payer and are not covered under United Mine Workers; begin
receiving an initiating cancer therapy for an included cancer type from a model participant; and do not have end-stage
renal disease.
The Innovation Center aims to implement OCM nationally. However, the geographic scope of the model may be affected
by the level of participation from other payers.
OCM Payments
OCM-FFS would incorporate a two-part payment approach for participating oncology practices, creating incentives to
improve the quality of care and furnish enhanced services for beneficiaries undergoing chemotherapy treatment for a
cancer diagnosis. OCM-FFS’ two forms of payment would include a monthly per-beneficiary care management payment
for Medicare FFS beneficiaries, as well as a retrospective performance-based payment for OCM-FFS episodes. The perbeneficiary-per-month (PBPM) payment for enhanced services would offer participating practices financial resources to
aid in effectively managing and coordinating care for Medicare FFS beneficiaries, while the performance-based payment
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The Center for Medicare & Medicaid Innovation:
Preliminary design for an oncology-focused model
would incentivize participating practices to lower the total cost of care and improve care for beneficiaries over the 6month episode period. The PBPM payment amount would be based on the estimated practice costs to furnish the
enhanced services in OCM. The performance-based payment would be calculated based on the practice’s achievement
of Medicare savings and achievement on the performance-based payment measures listed in Appendix A. Both
payments would be in addition to the existing Medicare FFS payments from the Medicare Trust Fund.
Episode Definition
Included Cancer Types
OCM would include all cancer types. The Innovation Center would consider episodes to be potentially eligible for a
performance-based payment regardless of cancer type, unless the Innovation Center is unable to set accurate
benchmarks for certain low-volume cancers. The Innovation Center is currently analyzing benchmarking methodologies
in order to maximize the number of beneficiaries eligible for a performance-based payment.
Episode Initiation
OCM-FFS episodes would initiate on the date of an initial chemotherapy administration claim or an initial Part D
chemotherapy claim and would not include services provided prior to that date. The Innovation Center has devised a list
of likely and possible chemotherapy drugs that would trigger OCM-FFS episodes. The list includes endocrine therapies
but excludes topical formulations of drugs.
Services Included in the Episode
OCM-FFS episodes would include all Medicare A, B, and D services that FFS beneficiaries receive during the episode
period.
Episode Termination
OCM-FFS episodes would terminate six months after a beneficiary’s chemotherapy initiation or when the beneficiary
dies prior to the end of the six month chemotherapy episode. Beneficiaries continuing to receive chemotherapy at the
end of an episode would initiate a new episode, with a maximum of two episodes per beneficiary.
Beneficiary Attribution
Eligible beneficiaries would be attributed to the OCM-FFS participant that is actively managing each beneficiary’s cancer
treatment using an attribution rule that would incorporate information from claims for chemotherapy administration
and evaluation & management services.
Eligible Medicare beneficiaries would be notified by participating practices about OCM and its goals to improve their
care while reducing Medicare expenditures. Practices would advise beneficiaries that they have the freedom to choose
their health care providers and may choose a provider who is not participating in OCM.
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The Center for Medicare & Medicaid Innovation:
Preliminary design for an oncology-focused model
Benchmarking and Performance-Based Payment
Calculation of Possible Performance-Based Payments
The Innovation Center would calculate risk-adjusted benchmark expenditures based on historical data, trend the
benchmark expenditures to the performance period, and incorporate a discount that Medicare would retain to set the
target price for performance period episodes. The Innovation Center would leverage regional or national data to
increase precision for target prices for practices with a low number of episodes. The Innovation Center would perform a
retrospective reconciliation of actual performance period Medicare FFS expenditures against the target prices, and
participants would be paid up to the full difference through the performance-based payment. The amount of the
performance-based payment would potentially be reduced or eliminated if a participant’s performance on a range of
measures does not exceed established thresholds (see the Appendix A for the preliminary list of performance-based
payment measures).
Risk Adjustment Factors
The Innovation Center would risk adjust for characteristics that predict Medicare expenditures in the episode. In the first
year risk adjustment factors would include only those in Medicare administrative claims data. Examples include:
beneficiary characteristics, episode characteristics, disease characteristics, and types of services furnished. The
Innovation Center would collect additional information from practices, including cancer staging information, to consider
as risk adjustment factors in future performance years of OCM.
Risk Arrangements and Distribution of Performance-Based Payments
OCM-FFS would feature semi-annual retrospective reconciliation of episodes and distribution of performance-based
payments. The Innovation Center would remove OCM-FFS participants who do not achieve performance-based
payments by the end of the third model year.
OCM-FFS would include only one-sided risk in the first model year. In the one-sided risk arrangement, any OCM-FFS
participant whose performance year actual expenditures exceed the target price would not be financially responsible for
additional costs. After the second model year, participants would be able to switch to two-sided risk on a semiannual
basis, in which the participant would be financially responsible for Medicare FFS expenditures that exceed the target
price. The Innovation Center would expect to set the discount at a lower rate for participants in the two-sided risk
arrangement.
Beneficiary Experience
Medicare FFS beneficiaries would be notified of their physician’s participation in OCM and the goals of OCM.
Participating practices would be required to work with the beneficiary to establish treatment goals and care plans. In
addition, the practice will be required to educate the beneficiary on the expected response to treatment and treatment
benefits and harms, including common and rare toxicities and how to manage these toxicities, as well as short-term and
late effects of treatment. The Innovation Center would monitor many aspects of the beneficiaries’ care to ensure that
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The Center for Medicare & Medicaid Innovation:
Preliminary design for an oncology-focused model
appropriate, high-quality care is furnished to OCM beneficiaries. The Innovation Center would also monitor the
beneficiary’s performance status during the chemotherapy episode.
Summary of Opportunity
OCM would offer individuals with cancer the opportunity to benefit from better quality care with a focus on enhanced
care-coordination services and patient-centered care; practices the opportunity to improve care for their patients, lower
costs, restructure to furnish more comprehensive care for oncology patients, and engage with quality and cost data that
would inform care redesign; and payers the opportunity to improve care for their members, lower costs, and engage
with quality and cost data that would inform changes to quality monitoring and payment delivery.
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The Center for Medicare & Medicaid Innovation:
Preliminary design for an oncology-focused model
Appendix A: Oncology Care Model Practice Requirements, Performance-Based Payment Measures, and Quality
Monitoring Measures
Purpose
Quality Domain
Practice
Requirements
Communication
and Care
Coordination
Recommended practice requirement or quality measurement
Employment of one or more designated patient navigators/care
coordinators
Attestation of meaningful use of electronic health records (EHRs)
certified by the Office of the National Coordinator for Health Information
Technology (ONC)
Electronic documentation of a care plan that contains the 13
components in the IOM Care Management Plan
Provision of and attestation to continuous patient access (24 hours per
day, 7 days per week) to an appropriate clinician who has real-time
access to practice’s medical record
Attestation that beneficiaries are treated with therapies compliant with
nationally recognized clinical guidelines or have documented reason for
not following guidelines
Number of emergency department visits per attributed OCM-FFS
beneficiary per OCM-FFS episode
Number of hospital admissions per attributed OCM-FFS beneficiaries per
OCM-FFS episode
Percentage of all Medicare FFS beneficiaries managed by a practice who
are admitted to hospice for less than 3 days
Percentage of all Medicare FFS beneficiaries managed by a practice who
experience more than one emergency department visit in the last 30
days of life
Performancebased payment
Person-and
CaregiverCentered
Experience and
Outcome
Communication
and Care
Coordination
Quality
Monitoring
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Percentage of attributed OCM-FFS beneficiary face-to-face encounters
with the participating practice in which there is a documented plan of
care for pain AND pain intensity is quantified
Score on patient experience survey (CAHPS as modified by the evaluation
contractor)
Percentage of attributed OCM-FFS beneficiary face-to-face encounters in
which the patient is assessed by an approved patient-reported outcomes
tool. This would include a minimum of the PROMIS tool short forms for
anxiety, depression, fatigue, pain interference, and physical function
Percentage of attributed OCM-FFS beneficiaries that receive psychosocial
screening and intervention at least once per OCM-FFS episode
Percentage of attributed OCM-FFS beneficiaries with at least one
palliative care consultation per OCM-FFS episode
Mortality rates of attributed OCM-FFS beneficiaries, risk-adjusted
Number of emergency department visits per attributed OCM-FFS
beneficiary in the 6 months following the OCM-FFS episode
Number of hospital admissions per attributed OCM-FFS beneficiary in the
6 months following the OCM-FFS episode
Number of hospital readmissions per attributed OCM-FFS beneficiary
during the OCM-FFS episode and the following 6 months
Number of ICU admissions per attributed OCM-FFS beneficiary during the
OCM-FFS episode and the following 6 months
Proportion of all Medicare FFS beneficiaries managed by a practice not
NQF #
Source
Reported by practice
Collected by CMS
Reported by practice
Reported by practice
Reported by practice
Claims data
Claims data
#0216
Claims data
#0211
Claims data
#2100
Reported by practice
Administered by
CMS contractor
Reported by practice
Reported by practice
Reported by practice
Claims data
Claims data
Claims data
#1789
Claims data
Claims data
#0215
Claims data
The Center for Medicare & Medicaid Innovation:
Preliminary design for an oncology-focused model
Purpose
Quality Domain
Clinical Quality of
Care
Population Health
Efficiency and Cost
Reduction
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Recommended practice requirement or quality measurement
admitted to hospice
Proportion of all Medicare FFS beneficiaries managed by a practice
receiving chemotherapy in the last 14 days of life
Percentage of attributed OCM-FFS beneficiaries that receive a follow-up
visit from the participating practice within 7 days after discharge from
any inpatient hospitalization
Percentage of face-to-face encounters between an attributed OCM-FFS
beneficiary and a participating practice which include medication
reconciliation
NQF #
#0210
Source
Claims data
Claims data
Reported by practice
Breast Cancer: Hormonal therapy for Stage IC-IIIC (ER/PR) Positive Cancer
in OCM-FFS beneficiaries
#0387
Reported by practice
(or claims data once
stage is reported)
Breast Cancer: Combination chemotherapy is considered or
administered within 4 months (120 days) of diagnosis for women under
70 with AJCC T1c, or Stage II or Stage III hormone receptor negative
breast cancer in OCM-FFS beneficiaries
#0559
Reported by practice
Colon Cancer: Chemotherapy for Stage IIIA through Stage IIIC OCM-FFS
beneficiaries with colon cancer
#0385
Reported by practice
(or claims data once
stage is reported)
Colon Cancer: Adjuvant chemotherapy is considered or administered
within 4 months (120 days) of surgery to OCM-FFS beneficiaries under
the age of 80 with AJCC III (lymph node positive) colon cancer
#0223
Reported by practice
Prostate Cancer: Adjuvant hormonal therapy for high-risk OCM-FFS
beneficiaries
#0390
Reported by practice
(or claims data once
stage is reported)
Percentage of OCM-FFS beneficiaries with documented ECOG, Karnofsky,
or WHO performance status assessment prior to OCM-FFS episode
initiation and at episode conclusion
Percentage of attributed OCM-FFS beneficiaries that receive tobacco
screening and cessation intervention at least once per OCM-FFS episode
Percentage of attributed OCM-FFS beneficiaries that have an Influenza
Immunization
Number of attributed OCM-FFS beneficiaries enrolled in clinical trials at
any point during an OCM-FFS episode
Prescription drug utilization by attributed OCM-FFS beneficiaries under
Medicare Part B and Part D
Radiation utilization by attributed OCM-FFS beneficiaries
Imaging utilization by attributed OCM-FFS beneficiaries
Post-acute provider utilization by attributed OCM-FFS beneficiaries
Outpatient therapy service utilization by attributed OCM-FFS
beneficiaries
Reported by practice
#0028
Reported by practice
#0041
Claims data
Claims data
Claims data
Claims data
Claims data
Claims data
Claims data
The Center for Medicare & Medicaid Innovation:
Preliminary design for an oncology-focused model
Appendix B: Components of the IOM Care Management Plan
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Patient information (e.g., name, date of birth, medication list, and allergies)
Diagnosis, including specific tissue information, relevant biomarkers, and stage
Prognosis
Treatment goals (curative, life-prolonging, symptom control, palliative care)
Initial plan for treatment and proposed duration, including specific chemotherapy drug names, doses, and
schedule as well as surgery and radiation therapy (if applicable)
Expected response to treatment
Treatment benefits and harms, including common and rare toxicities and how to manage these toxicities, as well
as short-term and late effects of treatment
Information on quality of life and a patient’s likely experience with treatment
Who will take responsibility for specific aspects of a patient’s care (e.g., the cancer care team, the primary
care/geriatrics care team, or other care teams)
Advance care plans, including advanced directives and other legal documents
Estimated total and out-of-pocket costs of cancer treatment
A plan for addressing a patient’s psychosocial health needs, including psychological, vocational, disability, legal,
or financial concerns and their management
Survivorship plan, including a summary of treatment and information on recommended follow-up activities and
surveillance, as well as risk reduction and health promotion activities
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