Regulatory changes for community oncology: What health execs should know
To quote Jacob Bronowski, author of The Ascent of Man: the search for knowledge through science “is an unending adventure at the edge of uncertainty.”
That uncertainty may seem somewhat vaster today with so many regulatory changes in the air for community oncology.
Among other things, there is a new administration in Washington with a new healthcare agenda, the contours of which are just beginning to come into view, but which is expected to increase the free care and bad debt burden on oncology providers.
Other regulatory changes include:
The beginning of MACRA, with hard choices for oncologists between participating in the Merit-Based Incentive Payment System (MIPS) or the Advanced Alternative Payment Model (APM) pathway, and figuring out how to succeed on either of those tracks;
The start of the Medicare Oncology Care Model (OCM), testing episode of care payments for chemotherapy services; and
The recent Bipartisan Budget Act and 21st Century Cures Act, leveling Medicare payments between hospitals and physicians for most off-campus cancer facilities, funding the Biden Cancer Moonshot with $1.3 billion, and reforming the drug and medical device approval process to help speed new discoveries to market.
The Oncology Care Model
One thing that is unlikely to change under the Trump Administration is the goal of reducing the cost of healthcare through various alternative payment initiatives. For example, the OCM, launched on July 1, 2016, is likely to be preserved. It is a significant experiment in transitioning to value-based oncology care, with 196 oncology providers and 17 health plans participating over the next five years.
OCM-participating oncology practices can qualify to be paid a Monthly Enhanced Oncology Service (MEOS) payment of $160 for each six-month episode of chemotherapy care for their cancer patents, in addition to their usual Medicare fee schedule payments.
OCM-participating practices also have the opportunity to earn a performance bonus based on meeting quality standards and achieving cost savings in relation to the practice’s target price for each chemotherapy episode.
The MEOS payment is intended to help participants effectively manage and coordinate care for oncology patients during episodes of care, while the performance-based payment is intended to incentivize practices to lower the total cost of care and improve care quality.
OCM-participating practices can choose either a one-sided or two-sided risk track. The one-sided track involves a target price with a 4% discount to historic costs before the practice shares in cost savings. The practice can only remain on the one-sided track if it earns an OCM performance bonus by mid-2019 by meeting the applicable quality standards and reducing costs by more than 4%.