New 2021 CMS Programs Affecting Value-Based Care

In previous posts we talked about the impact value-based care has had in the last several years, especially relating to the Centers of Medicare and Medicaid Services (CMS). In this post we will look at what is happening now in 2021.

CMS has been focused on rolling out new or updated alternative payment models (APMs) starting this year, with a prospective twist. Applying lessons learned from the rollout of multiple Center for Medicare and Medicaid Innovation (CMMI) programs, CMS is able to better construct more meaningfully relative value-based care (VBC) initiatives. As a result, CMS is offering to share more of the financial risk with the proposed new models. This trade-off gives the provider more potential for impact in patients’ lives while holding the provider more accountable for the outcome of that care. The new models starting in 2021 are proving to be a real signal of the pivot CMS is taking with value-based care and payments.

Cancer Treatment Programs

With relation to cancer treatment, there are two main programs slated for 2021: The Oncology Care First (OCF) and the Radiation Oncology (RO) models. OCF is designed as the replacement for the Oncology Care Model (OCM), which will be retired at the end of 2020. In the OCF model, a provider is paid a prospective, monthly population payment (MPP) based on Evaluation and Management (E&M) attribution methodology. This model includes patients receiving chemotherapy or hormone therapy, as well as patients who are cancer survivors, receiving follow-up care. The prospective payments are based on median national historical Medicare payments, during a fixed, historic baseline with a participant-specific risk adjustment. It is a total cost of care model that spans for 6 months at a time. Based on the provider’s quality performance for members that are in Medicare fee-for-service Part B or D chemotherapy, the provider can receive performance-based payments (PBP) or may have to pay CMS back. This is a new strategy that takes aspects from some of CMS’ primary care model approaches. Given how poorly OCM did overall, CMS is directly applying the insights gained to the OCF model.

The Radiation Oncology (RO) Model has a definitive, straightforward approach in its design, compared to other value-based programs, and can easily expand into other lines of business besides Medicare. In this prospective model, the payment is split between the provider and the facility, unless they are one in the same. Attribution is based on the radiation treatment plan CPT code, coupled with the first treatment facility location. The RO episode has a 90-day post period, covering radiation treatment only. There is a 30-day “clean period” before a new RO episode can start which prevents episode overlap. This simplified program structure allows for simplified pricing. Some RO quality metrics involve provider reporting; however, the main measures can be done purely through claims analysis. This model has been made mandatory in multiple MSAs with an originally intended start date of 1/1/2021. Nevertheless, the mandatory start has been pushed back twice due to technology concerns by providers, including updating their specific radiation oncology reporting portal(s). The program will now be mandatory starting 1/1/2022.

New Primary Care First Program

Primary Care First is a new program in 2021 that is based on CMS’ CPC+ program. Offered in 26 regions (including many state-wide regions), it comprises various five-year payment options that are based on an ACO primary care model. Practices will be incentivized to deliver patient-centered care that reduces the need for costly emergency department visits or inpatient hospital utilization. Primary Care First is oriented around universal primary care functions such as access and continuity, care management, and population health management. The program allows primary care practices to take on risk in exchange for lowering administrative costs associated with performance-based payments. It is an open-sourced approach (other payers can utilize the design) and focuses on actionable provider reporting. This model contains a 50% shared savings upside risk model tied to quality metrics, with only a 10% downside risk. Practices must have at least 125 attributed Medicare members to participate in any location, be willing to share data through the regional HIE and APIs, and have participated in a value-based program prior. The intent of this program is to standardize the primary care methodology in the healthcare space, while also being extremely transparent with data and reporting.

This year, 2021, is proving to be a real signal of the pivot CMS is taking with value-based care and payments. 2020 made quite an impact in demonstrating healthcare gaps and opportunities, and CMS has learned through experimentation over the years in their CMMI programs. The unveiling of these APMs for 2021 shows that CMS is maturing in its approach and that they are expecting providers to do the same. In the next segment, we will look at where CMS is headed in the future.


CMS: Radiation Oncology Model

Oncology Care First Is a Big Step Toward Bundled Payments in Cancer Care 

CMS: Primary Care First Model Options

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