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:
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.
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:
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.