The pMD Blog

Welcome to the
pMD Blog...

where we cover interesting and relevant news, insights, events, and more related to the health care industry and pMD. Most importantly, this blog is a fun, engaging way to learn about developments in an ever-changing field that is heavily influenced by technology.


pMD’s Care Coordination solution is empowering oncology practices to navigate new performance-based, episodic payment models for cancer care.  

In 2017, the Centers for Medicare and Medicaid Services (CMS) launched a new payment and care delivery model for the treatment of cancer patients.  The Oncology Care Model (OCM) was created to improve care quality while lowering cost by incentivizing practice redesign towards oncology care coordination. Applications were submitted to CMS, which ultimately selected nearly 200 U.S. physician practices to participate in the OCM.  The model also included 14 payers, meaning that Medicare will not be the only payer participating.  Inclusion of other payers supports the main goal of the OCM, as stated by CMS, to incentivize practice-wide care transformation, not to just improve care coordination for Medicare beneficiaries but for all oncology patients.

To participate in the OCM, practices were required to implement 6 redesign activities which included providing patients with 24/7 access to a clinician, the utilization of patient navigation and care coordination services, and the collection and analysis of data for continuous quality improvement, among others.

OCM redesign activities sought to address the challenging nature of delivering coordinated oncology care across a team of clinical and support staff. One patient’s treatment may be administered over several months.  High-risk patients may require more frequent intervention.  Oral chemotherapy patients may require timely interaction for symptom management given they receive treatment outside of the clinic, increasing the risk that patient concerns may go unreported. And post-treatment follow-up may extend over several decades.

Evolution of Care Navigation

The utilization of clinical nurse navigators supporting education and coordination as “air traffic controllers” for care is not new to oncology.  But navigator support under the OCM may now extend to manage urgent care appointment slots or to triage patients after hours all in a time when appropriate use of emergency department and or hospital resources is even more important.  

Additionally, the utilization of non-clinical navigators can greatly impact both care quality and patient satisfaction.  Duties may include support coordinating treatment appointments, facilitating communication between clinical nurse navigators, and orchestrating other patient-centric support services, including financial counseling, psychosocial programs, and patient transportation.


Image: Centers for Medicare & Medicaid Services

*There are 192 practices (List) and 14 payers participating in the Oncology Care Model

Through the OCM, CMS incentivizes practices to implement clinical and non-clinical navigation services in two ways.  First, in addition to standard fee-for-service payment, practices will receive a per-beneficiary-per-month payment (PBPM) for each six-month treatment episode that initiates with outpatient chemotherapy. And secondly, practices will also be eligible for performance-based payments based on a number of factors including managing the cost of each care episode, meeting quality requirements, and receiving high marks in patient satisfaction.  But the question remains: what is the correct level of staffing and/or intervention to produce higher-quality at a lower cost?

Data-powered Quality Improvement

An organized tracking system that easily collects information on various patient interactions across the care team is vital not only for successful implementation of the OCM but also in delivering high-quality care.

The coordination of patient-centric activity among clinical and non-clinical navigators and support staff is a need many OCM practices have identified.  Capturing patient call type, frequency, and duration plus face-to-face patient interactions provides practices the insight necessary to appropriately resource these services. Further, when patient engagement data is tied to clinical outcomes, then a model for care coordination emerges that can be copied and scaled based upon patient volume, diagnosis, and risk scoring.  And activity data further supports care quality discussions with payers.

pMD’s Care Coordination solution includes expertise and technology to help practices meet the navigation requirements of the OCM. But care coordination is vital beyond oncology and the OCM.  pMD is passionate about helping practices to manage the complexity of care delivered across specialities supporting all care communities.  If you have any questions or would like to find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, and care coordination software and services, please contact pMD.

With the growth of CMS’s Alternative Payment Models, the moments when physicians directly care for patients - the points of care - are getting vastly more complicated and information-needy. Let’s take a look at why and how this is happening!

The Environment
Recently, CMS set a clear path to creating new risk sharing programs for providers through alternative payment models such as Bundled Payments for Care Improvement (BPCI), which my colleague Tracy outlined well in this terrific post. The broad based BPCI program gave way to more specialty specific programs such as the Oncology Care Management Model, Nephrology’s ESRD Care Model, and Orthopedics’ Comprehensive Care for Joint Replacement model.

Collectively these programs signal a new era where previously disparate episodes of care are financially bound together. The new twist is that the payments, and hence risk, cover multiple providers and multiple sites of care. Now providers in different businesses are wrapped together in common financial risk, where before they operated independently. This new dependence asks more of each patient encounter and as a result, communication and coordination needs are growing exponentially.

These new alternative payment programs have a common general structure. First, each requires a risk period that includes all patient costs over a period ranging from 30 to 90 days. Second, each requires certain quality metrics be met. Third, each requires certain financial outcomes usually obligating an organization to operate at lower than its historical cost over the risk period. The organization can earn bonuses if the cost performance is below historical cost, or they must repay CMS for any costs that run above historical cost.

The first two elements trigger a need to work collaboratively with other caregivers given that most patients receive care from a variety of providers over such time periods. The last element, financial outcomes, acts to incentivize broad engagement since it can reward physicians with bonuses. Organizations can theoretically make up to a 50% bonus on their Medicare reimbursements occurring within the program. Taken together, these elements: risk, quality, and financial performance, require providers to be particularly attentive to the decision-making around patients in these programs. Each decision made at the point of care by an individual provider affects risk, quality, and finances not only for themselves, but also for every provider involved in the program.

On the Ground
Given this new importance of decision making at the point of care, there is a lot of new information to consider. Each risk period starts in the hospital and follows the patient into their post acute outpatient settings, which are typically owned by a different entity than the hospital. Thus, doctors at the point of care need to evaluate information such as:

• What is the site of care best suited for the patient’s condition: a skilled nursing facility, Home Health, inpatient rehab, or acute long term care?
• What site of care promises the best outcomes?
• Which particular provider will do the best job with that particular patient’s diagnosis and needs?
• How do we discuss this with the family and their particular dynamics and medical literacy?
• What quality measures are unmet for that patient?

How to get all of this information to the provider at the point of care - where decisions about the best, most effective care path for the patient must be made - is a growing problem. Further complicating matters are:

• The availability and continuity of the hospital case managers who have a primary responsibility to get patients discharged from the hospital in a timely manner;
• The many physicians who may be on the case with their demanding caseload;
• The frequent uncertainty of who would follow the patient post discharge and the families’ desire to have the patient’s needs fit into their busy lives.

All in all, this is a lot of new information to address at the point of care, and some of it quite complex with many different and diverse audiences. These data points highlight the very real question of who will be consistently available to deliver the information needed.

So therein lies the challenges for success in any of these Alternative Payment Models. There are new outcomes to consider spanning up to 90 days of care across all care settings, many beyond your walls, with a quality scorecard to meet. All of this impacts financial risk if the goals aren’t met. It seems inevitable that technology must rise to the task of delivering this data at the point of care, if alternative payment programs are to ever succeed. However, the challenge for those who seek to enable with technology is how well they can understand this thicket of needs and help you build the right care network, around each patient, extending to all the places you need it to go, and to all the people you need involved. I came to pMD to tackle such complex issues. Here, we love your difficult challenges.