Oncology Care Model

The Oncology Care Model (OCM) is an episode-based payment system developed by the Center for Medicare and Medicaid Innovation. The multipayer model is designed for discrete instances of care, especially those involving chemotherapy, which triggers the six-month episode. The program combines fee-for-service (FFS) payments for established services, monthly payments for additional care under a structured guideline, and performance-based payments weighed against quality metrics and benchmarks.

OCM is part of a general move away from the FFS model, "which pays doctors and hospitals according to the number of procedures they do, toward value-based care, which pays based on what helps patients get better." This idea was advanced by the Affordable Care Act (ACA), which was signed into law on March 23, 2010. As of March 18, 2017^[ref], OCM is being utilized by 190 healthcare provider groups, which include over 3,000 physicians in the United States. Along with Centers for Medicare and Medicaid Services, the payment system is accepted by 16 other health care coverage programs in the US. The payment model went into operation in July 2016, and barring changes to the Affordable Care Act, is slated to run until 2021. Over this five-year period, it is estimated that the model will be used for $6 billion spent on medical care to 155,000 patients.

The program is a move by the CMS to shift its focus to include specialized care. The bundled design has been the source of praise and criticism for the payment system. The program has been criticized for not going far enough; that is not eliminating FFS altogether. Other criticisms include the lack of flexibility in allowing primary care physicians to conduct care as they see fit, the arbitrary nature of the time period or episode, the cumbersome burden of the reporting standards and how it penalizes practices for outcomes out of their control.

The Affordable Care Act mandated the creation of the Center for Medicare and Medicaid Innovation (CMMI) as part of the Centers for Medicare and Medicaid Services (CMS). It was created to test new "payment and delivery system models" to be used by "Medicare, Medicaid, and the Children’s Health Insurance Program." The legislation also created the accountable care organizations (ACO) model, which holds voluntarily-enrolled health care practitioners accountable to patients and third-party payers for the quality, appropriateness, and efficiency of its services. ACO introduced the concept of rewards based on savings or "shared savings," which would later be applied to OCM. However, the results were mixed, with "only 31 percent of the nearly 400 ACOs" being successful in seeing returns.

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