Assessment of Oncology Care Model Participation

Summary

This retrospective feasibility study utilized the 100% Medicare Fee-For-Service (FFS) database to examine G-code billing usage among providers participating in the Oncology Care Model (OCM). OCM-participating providers were required to bill using the G-Code G9678 ensure receipt of monthly per-beneficiary per month payment for each OCM beneficiary being treated. The study period extended from July 1, 2016 through December 31, 2021. Providers who participated in the OCM were identified using National Provider Identification (NPI) and tax identification numbers (TIN) appearing within the FFS claims. Patients with multiple myeloma (MM), lung cancer or prostate cancer being treated by OCM-participating providers constituted the study sample. A total of 1,329 OCM providers treating 14,181 patients qualified for the study. Analyses revealed that approximately one-third of OCM providers utilized this G-code on claims to indicate the enhanced oncology services payment.

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Background

Between July of 2016 and July of 2022, the Center for Medicare and Medicaid Innovation implemented the Oncology Care Model (OCM) to improve the coordination and quality of oncology care, in addition to containing/lowering healthcare costs.^1,2 Participating practices entered into a payment arrangement with the Centers for Medicare and Medicaid Services (CMS) which included financial and performance accountability for episodes of chemotherapy administration, with the aim of providing enhanced services such as care coordination, navigation, and the use of national treatment guidelines for care.¹ Oncology practices received a monthly stipend of $160 per beneficiary, with the potential to earn performance-based payments for meeting quality and cost goals.² This study used the 100% Medicare Fee-For-Service (FFS) database to understand the demographic characteristics and impact of the G-code enhanced monthly payment among patients with multiple myeloma (MM), lung cancer, and prostate cancer who did and did not participate in the OCM.

Results

The final OCM sample included 1,332 providers treating 14,379 MM, lung cancer, and prostate cancer patients. The median patient age was 72.0, and the majority of the sample was comprised of white males resided in the southern region of the United States (Table 1).

Table 1. Demographic characteristics of patients by OCM provider participation

Analysis of the G-code utilization revealed that between 34.4% and 42.4% of OCM providers submitted at least 1 claim with a G-code for their cancer patient panels between 2016 and 2020 (Table 2).

Conclusions

Participation in OCM was higher in the southern and mid-Atlantic regions,⁴ which is also consistent with our findings showing that 67.8% of patients with an OCM provider were located in the southern and northeast regions. The relatively low G-code utilization associated with OCM participation either highlights the complexity in identifying true program enrollment/disenrollment rates using administrative data, or is an indication of the administrative burden of program participation.

Methodology

This retrospective analysis used the 100% Medicare FFS database through a research-focused data use agreement with the Centers for Medicare & Medicaid Services. Providers who participated in the OCM were identified using NPI numbers and TINs appearing within the FFS claims. Patients with multiple myeloma (MM), lung cancer or prostate cancer being treated by OCM-participating providers constituted the study sample. Patients were identified by the presence of  >1 inpatient claim in the primary position or > 2 outpatient claims in any position with a diagnosis code for MM, prostate cancer or lung cancer between July 1, 2016 through December 31, 2021. All patients were also required to present >1 claim for chemotherapy, systemic therapy, or targeted therapy.

Notes

1. CMS Innovates. Oncology Care Model | CMS Innovation Center. 2022.

2. Centers for Medicare and Medicaid Services. Synthesis of evaluation results across 21 Medicare Models, 2012-2020.

https://innovation.cms.gov/data-and-reports/2022/wp-eval-synthesis-21models

3. Andrea Hassol, et al. Evaluation of the Oncology Care Model: Performance Periods 1-6. https://innovation.cms.gov/data-and-reports/2021/ocm-ar4-eval-payment-impacts

4. Parikh RB, Bekelman JE, Huang Q, Martinez JR, Emanuel EJ, Navathe AS. Characteristics of physicians participating in Medicare’s oncology care model bundled payment program. J Oncol Pract. 2019;15(10).