By Matt Devino, MPH
On June 27, the Centers for Medicare & Medicaid Services (CMS) announced the long-awaited successor to the Oncology Care Model (OCM)—the Enhancing Oncology Model (EOM). Like the OCM, the EOM is a voluntary, multi-payer model, meaning that commercial payers, Medicare Advantage plans, and state Medicaid agencies are also eligible to apply to align their payment methodologies with the model. Also like the OCM, EOM participants will be responsible for the total cost of care during a six-month episode that is triggered by the receipt of an initiating anti-cancer therapy for an included cancer type. Many other elements of the OCM will remain the same in the EOM, including drug payments counting toward the total cost of care responsibility and participant redesign activities.
New to the EOM is the addition of two requirements to implement a social needs screening tool and electronic patient reported outcomes. And there are several other key differences between the OCM and EOM that interested applicants should consider before agreeing to participate in the model:
Downside Risk Required from the Start
The OCM was largely a upside-only risk model, where participants were able to earn performance-based payments if they generated savings when compared to the model’s risk-adjusted historical benchmarks. In the OCM, participants that had not earned a performance-based payment by the initial reconciliation of performance period four were required to accept downside risk, beginning in the eighth performance period, or be terminated from the model. Any OCM participants that had generated sufficient savings by performance period four had the option to remain in the one-sided risk track for the remainder of their participation.
On the other hand, all EOM participants will be required to select one of two risk arrangements, including downside risk, at the model’s start. In the less aggressive risk arrangement, the upside risk will be 4 percent of the benchmark amount and downside risk will be 2 percent. In the more aggressive risk arrangement, the upside risk will be 12 percent of the benchmark amount and the downside risk will be 6 percent. In both risk arrangements, if a participant’s performance period episode expenditures are greater than 98 percent of the benchmark amount, they will owe a performance-based recoupment. Participants may still earn this recoupment if their expenditures are less than the target amount.
Ultimately, the requirement to take downside risk from the start of the model may prove to be a significant disincentive for many cancer practices interested in participating in the EOM, particularly if they do not have prior experience in the OCM or another two-sided risk model. Even those with prior experience will be paying keen attention to the specifics of the EOM’s pricing methodology and price prediction models to analyze whether it will be possible to achieve savings and avoid owing a performance-based recoupment.
Reduced Payments for Enhanced Oncology Services
One important financial element of the OCM was the ability for participants to submit claims for a per-beneficiary per-month payment amount for “enhanced services,” called the Monthly Enhanced Oncology Services (MEOS) payment. These enhanced services included 24/7 access to a clinician, patient navigation services, documentation of a care plan, and treatment being consistent with nationally recognized clinical guidelines. In the OCM, the MEOS payment amount was $160 per beneficiary per month, all of which was included in the participant’s total cost of care responsibility. Under the EOM, CMS has reduced the MEOS payment by more than half ($70 per beneficiary per month). However, for dual eligible beneficiaries, participants can bill for an additional payment of $30 (for a total of $100 per beneficiary per month), but the additional $30 will not be included in the total cost of care responsibility.
The significant reduction in MEOS payments is another point of concern for cancer practices that are considering EOM participation, given that MEOS payments were necessary to subsidize required practice transformation activities in the OCM. While the additional MEOS payment for dual eligible beneficiaries is a nice incentive to encourage participation from practices who treat underserved communities, it is yet to be seen whether that incentive will outweigh concerns around the potential for losses due to required downside risk.
Fewer Included Cancer Types
Nearly all cancer types were included in the OCM. In designing the EOM, CMS has removed beneficiaries who are exclusively receiving hormonal therapies and limited the scope of the model to systemic chemotherapy treatment for just seven cancer types: breast cancer, chronic leukemia, small intestine/colorectal cancer, lung cancer, lymphoma, multiple myeloma, and prostate cancer. As CMS indicated, “These cancer types were selected because they are all prevalent cancer types treated in the United States and all have sufficient Medicare claims data for CMS to calculate benchmark prices for episodes among the Medicare [fee-for-service] population for purposes of [the] EOM.”
The reduction in the cancer types included in the EOM is beneficial because it will allow CMS to create separate price prediction models, trend factors, and novel therapy adjustments specific to each cancer type. The lack of specificity in the OCM payment methodology resulted in negative experiences for cancer practices that treat more high-cost cancers and unequal opportunities for savings for those treating lower-acuity patients. However, this narrowing of the EOM also represents a shrinking of the risk pool, and, as one practice put it, “Smaller risk pools under full-risk scenarios is always concerning.”
New Focus on Health Equity
Finally, the EOM seeks to address health equity in a way its predecessor did not—at least not explicitly. Model participants will be required to screen beneficiaries for health-related social needs, collect and submit beneficiary sociodemographic data, and develop health equity plans to show how they will address disparities and promote equity within their patient population. CMS has indicated that it may use reported sociodemographic data to share “certain aggregate, de-identified data…stratified by sociodemographic metrics (e.g., dual status, [low-income subsidy] eligibility, and race and ethnicity)” as well as for other monitoring and evaluation purposes. This focus on health equity is intended to align the model with CMS’s strategic refresh and President Biden’s relaunched Cancer Moonshot, both of which prioritize the advancement of health equity.
Cancer practices are largely supportive of this new model element, given that social needs play a significant role in clinical outcomes. While many past OCM participants are already screening for health-related social needs and collecting patients’ sociodemographic data, the reporting of this data allows for standardization and the opportunity for participants (and the broader healthcare community) to begin addressing disparities in cancer treatment and outcomes in a concerted and meaningful way.
Application & Implementation Timeline
The first EOM performance period is set to begin on July 1, 2023. Physician group practices interested in participating must complete an application through the EOM application portal by September 30, 2022. Applications are nonbinding, and the submission of an application is not an obligation to participate in the model. Approved applicants will receive a participation agreement, which will need to be signed in early 2023, formally confirming the cancer practice’s participation in the EOM.
Additional information on the model and its application process can be found on the CMS website and EOM request for applications.
Matt Devino, MPH, is the director of Cancer Care Delivery and Health Policy at ACCC.
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