Understanding Medicare's Oncology Care Model

Some of you may have received a letter from your oncologist notifying you that your oncologist is participating in a program called the Oncology Care Model. This letter was sent out to all Medicare patients from their current provider. This letter informs you that you still have all the Medicare rights and protections including which health care provider you see. However, if you do not want to participate in this program, your opting out will require you to find a new provider. This can be very daunting for a patient that has been receiving care and established a relationship with their current provider. Keep reading for a brief overview of the Oncology Care Model, (OCM).

This program was developed by the Center for Medicare and Medicaid Innovation (Innovation Center), which was established by the Social Security Act and added to the Affordable Care Act. Its purpose was to test innovative payment and service delivery models to reduce program expenditures and improve quality for Medicare, Medicaid, and Children’s Insurance Program beneficiaries. The practices participating in this program have committed to providing enhanced services to Medicare beneficiaries (which includes care coordination and navigation), and to using national treatment guidelines for care.

Since a significant proportion of those diagnosed with cancer are over 65 years of age and Medicare beneficiaries, this provides the Center for Medicare and Medicaid Services (in partnership with oncologists, other providers and commercial health insurance plans), the opportunity to support better quality care, improved health, and lower cost for this patient population. It is intended to improve our nation’s health by providing clear measurable goals and a timeline to move Medicare and the US healthcare system toward paying providers on the quality of care rather than the quantity of care that they give their patients.

OCM focuses on Medicare Fee for Services beneficiaries receiving chemotherapy treatment and includes the spectrum of care provided to a patient during a six-month episode that begins with chemotherapy.

The benefit includes enhanced services such as: 

• The core functions of patient navigation to find other patient-focused resources
• A personalized care plan 
• Access (24 hrs./day, 7 days/wk) to an appropriate clinician who has real-time access to the patient's medical records and:
• Treatment with therapies consistent with nationally recognized clinical guidelines.

There is no additional cost to patients to participate in this program. Medicare will pay for the full amount of the services. There is however a survey that patients are asked to participate in to provide feedback to help improve care for all people with Medicare.

In a nutshell, the Oncology Care Model is a study using best patient service practices, best billing practices, and best treatment practices to enhance health care practice efficiencies and patient experience while reducing cost.

Talk to your treatment team to discuss any questions or concerns you have regarding this program and determine if it is right for you. You can also learn more from the Center for Medicare and Medicaid services here or call 1-800-MEDICARE (1-800-633-4227).

If you have questions about Medicare or other financial issues, consider talking to a Myeloma Coach with financial experience. Coaches are myeloma patients or caregivers willing to share their personal experiences as well as resources that have helped them and can help you. Diahanna is a Financial Coach with the Myeloma Coach program and has a team of Coaches with experience in financial resources.  

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