Cautious Optimism: OCM Participants Seem to Have Improved in Performance Period 2

After the first performance period (PP) 1 results that practices participating in the Oncology Care Model (OCM) received 6 months ago, it’s safe to say there was some discontent. Now, preliminary analysis of the recently released PP2 results has shown an improvement over PP1, according to Charles Saunders, MD, CEO of Integra Connect.

He noted that an early review of the data has shown a 40% improvement in the average performance-based payment reconciliation.

“That suggests that whatever programs were being put in place during PP1, [practices are] starting to get some traction with those in PP2, and they’re, maybe, starting to learn how to do the things necessary to generate savings and begin the practice transformation,” Saunders said.

However, those results could change to show a lesser increase compared with PP1 since hospital-based bills take longer than the 6 months that have passed since PP1. Those hospital claims can take 9 months to a year to come out. Still, Saunders is cautiously optimistic about the improvements over PP1 since there wasn’t much of a difference between the initial reconciliation and the true-up released later that encompassed claims that took longer than 6 months to run out.

Feedback on the direction of OCM, and potential changes.

Compared with PP1, Saunders noted that participants were a little surprised that the monthly enhanced oncology service (MEOS) recoupment payments were higher than anticipated. These payments are per beneficiary for the duration of the episode. That said, there needs to be better attribution logic for the MEOS payments—providers don’t always know if a patient is seeing another provider with a plurality of other evaluation and management (E/M) visits. This is not uncommon for noncomplex patients, such as those with breast cancer or dormant prostate cancer, who might be seeing their primary care doctor more than their oncologist.

“The oncologist goes ahead and bills the MEOS payment for the patient, but it turns out they’re ineligible, because [there was] a plurality of E/M visits from another provider,” Saunders explained. “So, all of those are disqualifying and get clawed back.”

The appeal process isn’t completely clear yet, either. A number of disqualifying events were appealed but denied by CMS for reasons that were unclear.

“I don’t think people fully know how that attribution logic is being applied,” he added.

Complex patients can be challenging, too, though. If the oncologists undercode the hierarchical condition category (HCC) by putting in the cancer diagnosis but not other issues, such as chronic obstructive pulmonary disease or congestive heart failure, the baseline price and target will be artificially low for how complex these patients actually are.

Saunders has seen practices where the performance and the target vary considerably because of the number of HCC codes. Practices with very few HCC codes tended to perform more poorly, while practices with a lot of HCC codes generally performed well against the target.

“You can hypothesize that it’s because either complex patients have a lot of savings opportunities because they’re such high-resource consumers, or because the low-coded HCC individuals [should have been] high coded, but somebody wasn’t doing the coding,” Saunders said.

Saunders hopes that CMS continues to listen to the feedback provided by OCM participants for program improvement. He compared the OCM with the Medicare Shared Savings Program (MSSP), which took the proven concept of accountable care organizations and created a program based on gain sharing. MSSP required large upfront investments, as well as cultural changes. Initially, few health systems generated any savings, but CMS made positive adjustments to the program based on input from the participants.

He hopes to see the same thing take place in the OCM.

“I think the OCM model is actually a better model because it provides ongoing upfront payments in the form of MEOS payments that can actually fund some of the investments needed,” Saunders said.