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In the previous e-blast, The Oncology Group talked about Medicare’s Oncology Care Model–a pilot program seeking to improve care coordination, appropriateness of care and access to care for Medicare beneficiaries undergoing chemotherapy. Medicare received more than 400 letters of intent from providers interested in participating in this program. This is a five-year pilot program, beginning sometime in spring 2016. Applications to participate in the program are currently closed. Those filing letters of intent who went on to complete a full application are now being evaluated by Medicare to participate in the Oncology Care Model.

Final provider participants will likely be announced in early 2016.

Medicare seeks to improve care coordination, appropriateness of care and access to care for Medicare beneficiaries undergoing chemotherapy. The Oncology Care Model is a two-part pilot program.

  • For those providers who have applied and are chosen to participate, Medicare offers a threefold reimbursement system combining traditional fee-for-service payments with a monthly per-patient payment of $160 and the opportunity to earn additional performance-based payments based on cost savings.
  • Medicare is also extending the program to private payers and state Medicaid agencies. It is selecting payers interested in financially incentivizing oncologists who develop programs similar to Medicare’s Oncology Care Model.

Contact The Oncology Group if you would like to know which practices or programs in your market submitted an application to participate in Medicare’s Oncology Care Model. CMS hopes to announce the selected payer and provider participants in early 2016.

Payers Can Join with CMS and Participate in the Oncology Care Model

Even more interesting is that Medicare is extending the program to private payers, covering both commercial and Medicare members, as well as state Medicaid agencies. CMS is hoping to encourage care transformation by engaging with other payers interested in aligning financial incentives, working together and thus broadening the impact and reach of all efforts. Payers interested in collaborating have applied to participate, and CMS is currently reviewing their applications.

Payers interested in joining the pilot program may either design their own oncology program or use the model proposed by CMS. In entering into an agreement with CMS to participate in the Oncology Care Model pilot program, payers must support the goals of care improvement and cost reduction. Similar to the process used for providers, payers filed letters of intent expressing their interest in working with CMS. Aetna, Anthem, Humana, Cigna and additional regional BlueCross Blue Shield Plans have all filed letters of intent. Shortly, CMS hopes to select those payers who will be offered the opportunity to participate in the pilot program. Once final payer participants join the CMS program, Medicare’s Innovation Center will collaborate with payers on a variety of activities, including the development of a set of core quality measures to be used by both Medicare and private payers.

As CMS and Private Payers Collaborate, Expect Market Changes

CMS’s Oncology Care Model may directly impact your practice as private payers collaborate with CMS and/or develop their own oncology care programs. By joining forces with private payers, CMS hopes to accelerate change. Any or all of the following could affect your practice:

  • Payers may require participation in the program in order to be a part of a preferred network.
  • Private payers may develop ways to steer patients to oncologists participating in the program.
  • Payers may increase the use of clinical care guidelines and refuse, limit or review care provided outside those guidelines.
  • Payers may incentivize participation by offering a higher fee schedule, additional reimbursement opportunities or other incentives to encourage oncology practices to participate in the new program.
  • Payers may require the submission of additional data from practices.

Your practice may feel the force of these changes, either positively or negatively. Program participation may grow your practice and offer additional revenue opportunities. Failure to participate–or inability to meet the expected targets–may have a negative impact on your practice, decreasing volume and reimbursement.

If you would like to know which payer in your market filed a letter of intent to participate in Medicare’s Oncology Care Model pilot program, please contact The Oncology Group. Our advisors are well-versed and up to date in every aspect of cancer programs. We can help evaluate your readiness for oncology care management programs and guide you through the process of participation. To get started, you may reach us at 512-583-8815 or [email protected].