On June 27, 2022, CMS announced CMMI's next episode-based medical oncology payment model, the Enhancing Oncology Model (EOM). This model is intended to iterate on the Oncology Care Model (OCM), which ended in June. Keep reading for more detail on the EOM based on CMS' Request for Applications (RFA) and our take on how the model compares to the OCM.
We will continue to add to this blog post as we learn more about the model.
What are CMS' goals with this model?
Will my organization have to participate?
How can my organization apply to participate?
Which beneficiaries are included?
What requirements must participants fulfill?
What data will be shared between CMS and EOM participants?
Does this model count as an advanced alternative payment model (APM)?
What are the two risk arrangements available to participants under the EOM?
How does the EOM differ from the OCM?
Is the EOM promoting use of telehealth and home-based care?
What are CMS' goals with this model?
Like the OCM, the EOM is intended to improve care quality and the cancer patient care experience while reducing spending. Unlike the OCM, the EOM also has an explicit goal of making cancer care more accessible and equitable by addressing health disparities.
This additional goal aligns with CMS' recent strategy refresh and the Biden administration's reignition of the Cancer Moonshot, both of which have emphasized addressing inequities as a major priority. The EOM design suggests CMS is taking this charge seriously, and the focus on health equity is one of the main elements that sets the EOM apart from the OCM.
When will the model start?
The EOM will start on July 1, 2023 and continue through June 30, 2028, covering nine six-month performance periods. Like the OCM, it includes six-month episodes of care.
Will my organization have to participate?
Participation in the EOM is voluntary and is open to all Medicare-enrolled physician group practices across the country with at least one oncology practitioner. Both oncology physicians and advanced practice providers that provide E&M services to Medicare patients undergoing chemotherapy can be considered EOM practitioners. CMS is specifically encouraging oncology practices who care for underserved beneficiaries to apply. As with the OCM, practices that routinely refer beneficiaries to PPS-exempt cancer hospitals for chemotherapy services are excluded from participating. Private payers and state Medicaid agencies are also invited to align with the model.
Since the EOM requirements are very similar to the OCM requirements, we anticipate that many OCM participants will also apply to participate in the EOM. But since providers in the EOM will start out with downside risk, fewer practices may choose to participate in the model compared to the nearly 200 that joined the OCM at the start. Practices that regularly secured performance-based payments and succeeded under two-sided risk in the OCM are especially well-positioned for participation.
How can my organization apply to participate?
Oncology physician group practices can apply now to participate in the EOM through the EOM RFA Application Portal. The deadline to apply is 11:59 PM ET on September 30, 2022. The application is non-binding; approved applicants will be given a participation agreement that they can choose to sign before the model starts.
An internal committee at CMS will review the applications based on completeness, quality of narratives, and the results of a program integrity screening, and will notify applicants if they have been approved to participate in late 2022 or early 2023.
Which beneficiaries are included?
The EOM includes Medicare fee-for-service beneficiaries receiving Part B or Part D systemic chemotherapy for seven cancer types: breast cancer, chronic leukemia, small intestine/colorectal cancer, lung cancer, lymphoma, multiple myeloma, and prostate cancer. Beneficiaries who only receive hormonal therapy, such as low-risk breast and low-intensity prostate cancer patients, are excluded. CMS has not yet decided whether beneficiaries with Covid-19 diagnoses during an episode of care will be included.
This means the EOM includes fewer beneficiaries than the OCM, which included nearly all beneficiaries that received systemic chemotherapy or hormonal therapy for all cancer types. Due to the nature of the cancer types included in the EOM, the model will be comprised of higher-risk and higher-intensity cancer episodes, which were shown under the OCM to have greater potential for cost-reduction.
What requirements must participants fulfill?
EOM participants are required to implement eight participant redesign activities, including:
- Offering beneficiaries 24/7 access to a clinician with real-time access to their medical records
- Providing patient navigation
- Documenting a care plan that contains the 13 components of the Institute of Medicine's Care Management Plan
- Adhering to nationally recognized clinical guidelines
- Using Certified Electronic Health Record Technology (CEHRT)
- Utilizing data for continuous quality improvement
- Screening for health-related social needs (HRSNs)
- Gradually implementing electronic Patient Reported Outcomes (ePROs)
The first six requirements were also included in the OCM, but the last two are new to the EOM. CMS has been thinking about implementing ePROs for a while now—this requirement was included in the informal RFI it published for the Oncology Care First model back in 2019. Screening for HRSNs is also not a surprising addition given that it aligns with CMS' goal of addressing health disparities.
Another new condition in the EOM is that as part of the requirement to utilize data for continuous quality improvement, EOM participants must develop a health equity plan showing how they will use evidence-based strategies to mitigate health disparities they identify in their patient populations. Participants will also have to report on patient sociodemographic data, and feedback reports from CMS will be stratified by these sociodemographic variables to help EOM participants identify disparities to address.
Finally, similar to the OCM, EOM participants will have to meet quality measures related to patient experience, avoidable acute care utilization, management of symptoms and toxicity, management of psychosocial health, and management of end-of-life care. Importantly, EOM participants will have the opportunity to reduce any recoupment amount owed to CMS by performing well on quality measures. We will be looking out for CMS' release of the specific quality measures sometime this summer or fall.
How will practices be paid?
EOM participants will receive fee-for-service reimbursement for all services they provide to enrolled beneficiaries. They can also earn performance-based payments (PBPs) by hitting spending targets and meeting the threshold for quality performance. Unlike in the OCM, all EOM participants will start out at risk for owing CMS a performance-based recoupment if their total cost of care exceeds the spending benchmark.
Like in the OCM, providers can also bill for monthly enhanced oncology services (MEOS) payments for each beneficiary. However, unlike the $160 MEOS payments providers received under the OCM, CMS will only pay EOM providers $70, with the potential to earn an extra $30 for dually eligible beneficiaries. This additional payment is meant to help practices better manage dually eligible beneficiaries, who may require more resource-intensive care management than other patients and have historically been associated with higher episode expenditures. While the initial $70 of each MEOS payment will be included in participants' total cost of care responsibility, the additional $30 for dually eligible beneficiaries will be excluded so as not to discourage participants from taking on Medicaid patients.
Interestingly, the $70 MEOS payment is nearly equal to the case management fee participants receive in UnitedHealthcare's Cancer Episode Program, which has so far been successful in reducing costs. It is also much closer to the amount Medicare would have needed to pay providers to break even in OCM performance period six, the latest OCM performance period for which data has been published. Though many practices told CMS they relied on the higher MEOS payments provided in the OCM to undergo quality improvement initiatives, a recent survey of OCM participants found nearly all practices would continue to participate if MEOS payments were reduced by half. This suggests that the lower MEOS payments in the EOM are not likely to be a significant participation barrier for many practices.
What data will be shared between CMS and EOM participants?
EOM participants will be responsible for electronically sharing three types of data abstracted from their own health IT with CMS:
- Quality measure data
- Clinical and staging data
- Beneficiary-level sociodemographic data.
CMS will (upon request) provide participants with:
- Quarterly feedback reports
- Semiannual reconciliation reports, attribution lists, and episode-level files
- Monthly claims data
In sharing monthly claims data with participants, CMS is improving on the long lag times that were a hallmark challenge of the OCM. Ideally, this level of consistent data sharing will enable EOM practices to better implement quality improvement initiatives and improve performance in real time.
Does this model count as an advanced alternative payment model (APM)?
Whether individual participants are considered to be participating in an Advanced APM or a MIPS APM under the Quality Payment Program (QPP) depends on which of the two risk arrangements they choose.
Risk arrangement 1 is less aggressive and is expected to qualify as a MIPS APM but not an Advanced APM. Risk arrangement 2 is more aggressive and is expected to qualify as both a MIPS APM and an Advanced APM.
What are the two risk arrangements available to participants under the EOM?
Risk arrangement 1 (RA1):
- Discount = 4% of benchmark amount
- Target amount = 96% of benchmark amount
- Recoupment threshold = 98% of benchmark amount
- Stop-gain = 4% of benchmark amount
- Stop-less = 2% of benchmark amount
Risk arrangement 2 (RA2):
- Discount = 3% of benchmark amount
- Target amount = 97% of benchmark amount
- Recoupment threshold = 98% of benchmark amount
- Stop-gain = 12% of benchmark amount
- Stop-loss = 6% of benchmark amount
Participants will be able to move between these risk arrangements between performance periods. This may mean we'll see participants start out in RA1 to gauge their performance potential before moving into RA2 later in the model.
How does the EOM differ from the OCM?
As mentioned above, compared to the OCM, the EOM includes beneficiaries with fewer cancer types; a lower MEOS payment with an adjustment for dually eligible beneficiaries; mandatory downside risk; and additional requirements to screen for HRSNs, implement ePROs, collect sociodemographic data, and create a health equity plan. There are several other changes CMS made in the EOM, including:
- Beneficiaries will be attributed to the practice that provides the first qualifying E&M service after chemotherapy has been initiated, as long as that practice provides at least 25% of cancer-related E&M services during the episode; otherwise, attribution goes to the practice with the plurality of E&M visits, similar to how beneficiaries were attributed in the OCM
- Novel therapy adjustments will be calculatedly separately for each cancer type instead of in aggregate
- Risk adjustment will be based on price prediction models that are unique to each cancer type, with more robust use of clinical and staging data reported by EOM participants
Is the EOM promoting use of telehealth and home-based care?
To support EOM participants in effectively managing patient care, CMS is waiving certain Medicare payment requirements for interested participants, including a telehealth benefit enhancement, post-discharge benefit enhancement, and care management home visit benefit enhancement.
The telehealth benefit enhancement will allow EOM practitioners to provide telehealth visits from any location to beneficiaries wherever they are located, rather than requiring both parties to travel to a health care facility. The post-discharge benefit enhancement will give auxiliary personnel the ability to conduct up to nine post-discharge home visits within 90 days of a beneficiary discharge under the general supervision of a physician or other practitioner, instead of under direct supervision. Similarly, the care management home visits benefit enhancement will enable auxiliary personnel to conduct home visits under general supervision (rather than direct supervision) in advance of potential hospitalization.
Together, these enhancements will make it easier for EOM participants to take a patient-centered approach to care and, hopefully, to improve savings, quality, and equity.
(Advisory Board is a division of Optum, which is a wholly owned subsidiary of of UnitedHealth Group. UnitedHealth Group separately owns UnitedHealthcare. All Advisory Board research, expert perspectives, and recommendations remain independent.)
Although CMS' recent cancer-specific alternative payment model has not demonstrated net savings thus far, there is still a lot that oncology stakeholders can learn from the experience of OCM participants that can be applied to other payment models, including CMMI’s newly announced Enhancing Oncology Model, to help ensure success.