Value-Based Reimbursement

Alternative Payment Models

Community-based cancer care is the most cost-effective setting for Medicare and its beneficiaries and The US Oncology Network continues to engage with the Centers for Medicare & Medicaid Services (CMS) in developing new value-based payment methods for cancer care.

Oncology Care Model/Oncology Care First Model

The US Oncology Network is committed to working with CMS to enhance the delivery of cancer care and protect patient access to high‐quality care in the most efficient manner. This dedication is demonstrated by the 15 oncology practices within The Network, encompassing more than 900 providers, that are participating in CMS’s Oncology Care Model. These practices have accepted the challenge of participating in the pilot with the shared goal of improved patient outcomes and cost savings for the Medicare program. Network practices have embraced innovation in both treatment options and care delivery, and are actively working to transition to value based care. In November 2020, The Network enrolled its 100,000th patient in OCM. In realizing this goal, the participating Network practices delivered more than $122 million in cumulative savings to Medicare over the program’s first six performance periods.

The US Oncology Network submitted comments to the Center for Medicare and Medicaid Innovation (CMMI) in response to its Request for Information (RFI) on the Oncology Care First (OCF) model. The OCF model would be a voluntary, five-year, total cost of care model intended as the successor to the OCM. The OCF model was originally slated to begin in January 2021, when there are no new episodes initiating in the OCM. However, due to COVID-19, CMMI extended the OCM for an additional year, delaying implementation of the OCF model.

Part B Drug Spending and MIPS

Many community oncologists also participate in the Merit-Based Incentive Payments System (MIPS) – a program created under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) that rewards physicians with bonuses for providing quality care and penalizes those who perform poorly. While MIPS’ goals are laudable, the system has presented physicians with numerous burdens that have hindered their ability to provide quality care.

One such burden has been the inclusion of Medicare Part B drug spending in the calculation of MIPS payment adjustments. In its 2018 Quality Payment Program final rule, CMS announced that it would begin to impose these payment adjustments to Part B drug payments in addition to physicians’ services under the Medicare fee schedule, a significant departure from past policy.

Including Part B spending in MIPS adjustments would have created substantial volatility for community oncologists, some of whom could have seen their reimbursements fluctuate by as much as 29% by 2020 according to an analysis from Avalere Health. And, because the physicians working in hospitals and hospital outpatient settings would be exempt from MIPS, this policy change would create an uneven playing field between settings of care. Furthermore, the including Part B spending in MIPS would only exacerbate the financial problems of small and rural providers who already shoulder the significant financial burden procuring and administering expensive Part B drugs.

Thanks to the advocacy efforts of The US Oncology Network and other cancer community stakeholders, Congress excluded Part B drug spending from MIPS adjustments as a part of a February 2018 spending agreement.

Additional Resources