On June 27, the Center for Medicare and Medicaid Innovation (CMMI) announced the Enhancing Oncology Model (EOM) and released a Request for Applications to solicit participation in the model, which will begin on July 1, 2023. This voluntary model builds on the structure and learnings of the Oncology Care Model (OCM) with an increased focus on managing provider risk, promoting patient-centric care, and addressing health disparities.

Like the OCM, the EOM maintains the Monthly Enhanced Oncology Services (MEOS) payments and potential for a performance-based payment (or recoupment), layered on top of fee-for-service payments. Under the EOM, participants will receive lower MEOS payments relative to the OCM MEOS and will be required to take on downside risk immediately, in an effort to generate net savings to Medicare. Additionally, the EOM includes fewer cancer types compared to the OCM, aligning with CMMI’s goal to streamline models and focus on the highest opportunities to realize savings and improve care. The 7 cancer types (far fewer than OCM’s 21 cancer types) included in the EOM are breast cancer, lung cancer, lymphoma, multiple myeloma, small intestine/colorectal cancer, prostate cancer, and chronic leukemia. The EOM is further limited to include only beneficiaries undergoing systemic chemotherapy.

The final OCM performance period ends June 30, 2022, and the EOM will not begin until July 1, 2023, creating a 1-year gap between the 2 models. While oncology providers will likely welcome the announcement of the new model due to the practice transformation focused on care delivery, the year-long gap may cause concern among current participants. Notably, the EOM may commence as the COVID-19 public health emergency (PHE) potentially subsides, but the delays and challenges in delivery of routine cancer care it caused has led to concerns that oncologists will be facing patients with more complex and advanced tumors. The EOM may offer a view on how alternative payment models (APMs) look in the “new normal” and shed light on possible hurdles in the post-PHE world.

Applications for participation in the EOM are due September 30. As stakeholders prepare for the model and continue to refine CMMI engagement priorities, they should evaluate 5 key considerations.

The EOM’s Focus on Health Equity Offers Opportunities to Close the Cancer Disparities Gap

The EOM’s focus on addressing social determinants of health (SDOH) offers new opportunities to close the cancer disparities gap.  As part of these efforts, the EOM includes 2 new practice redesign activities, in addition to the 6 from the OCM, focused on SDOH and providing patient-centric care. The new practice redesign activities include the gradual implementation of electronic patient-reported outcomes (ePROs) and screening beneficiary social needs using health-focused social needs screening tools. Stakeholders should consider how data that map cancer disparities to access and outcomes can inform targeted strategies for vulnerable or underserved patients. Additionally, CMS will pay higher MEOS payments for dual-eligible beneficiaries; this additional payment will not be included in model participants’ total cost of care responsibility. Increased MEOS payments may assist practices in better managing the health outcomes of dual-eligible beneficiaries, a small, but costly and complex subset of beneficiaries.

The EOM Payment Methodology Incorporates Cancer Type-Specific Adjustments to Construct Benchmarks

Some stakeholders criticized the OCM methodology, citing its inability to accurately predict the cost of cancer care given rapidly evolving treatment paradigms over 6-month episodes of care. Unlike the OCM, the EOM implements cancer type-specific methodology (e.g., trend factor, novel therapy adjustment) to establish benchmark/target prices. Employing cancer-type specific adjustments is intended to more accurately account for the heterogeneity in treatments and associated costs across different types of cancers. The EOM also includes clinical adjusters to account for metastatic status for some of the included cancer types and to adjust for HER2 status for breast cancer. As such, EOM stakeholders should understand the impact of these adjustments on benchmark prices, particularly in light of concerns that the PHE has increased the number of patients presenting with advanced disease due to factors such as delayed screening.

Increased Provider Risk and Reduced MEOS Payments to Shape Care Management

While OCM has been touted as a success among the models in CMMI’s portfolio, the Innovation Center did not realize the net Medicare savings it had anticipated through OCM. The lack of savings is due in part to the pandemic and the Center’s waiver of mandatory two-sided risk during the PHE. In an effort to reduce spending more quickly in the EOM, CMMI is shifting downside risk on providers more aggressively and reducing the MEOS payments.

EOM stakeholders should consider how increased provider risk and reduced MEOS payments may impact treatment selection and care delivery. Reduced MEOS payments may impact participants’ ability to make sufficient investments to realize efficiencies from enhanced care management services such as patient navigation and care planning. Provider risk arrangements will place added dependency on care management services and care coordination in addition to scrutiny on treatment plans and therapy selection.

The EOM Promotes a More Patient-Centered Approach that Will Impact Care Redesign Activities

The EOM aims to improve cancer care through a patient-centric approach via practice redesign activities, use of quality measures to adjust payments, and incorporating health equity. CMS has added the gradual implementation of ePROs and screening for patient social needs to the 6 redesign actives included in the OCM (e.g., patient navigation). Learnings from the OCM showed that investments in patient navigation and documenting care plans led to some improvement in patient experience of care and care at the end-of-life, but there is still opportunity for further improvement. Like the OCM, the EOM will include quality measures which are used to adjust performance-based payments via an aggregate quality score. The EOM plans to advance health equity by requiring participants to identify patient health disparities and submit health equity plans to CMS detailing evidence-based strategies to address them.

While the specific quality measures used for this program will not be released until Summer/Fall 2022, the overall quality program will focus on measures from 6 domains: patient experience, avoidable acute care utilization, management of symptoms and toxicity, management of psychosocial health, and management of end-of-life care. The OCM included 4 domains: communication and care coordination, person and caregiver experience and outcomes, clinical quality of care, and patient safety.  Ultimately the measures selected will be similar and will be continuously evaluated or new measures introduced.

The EOM’s Footprint Should Be Assessed Both Inside and Beyond Medicare

Looking ahead, stakeholders should evaluate the expected patient and provider footprint the EOM may have within Medicare and beyond. OCM participants committed to value-based oncology care are expected to participate in the EOM. Moreover, some EOM design elements such as the higher MEOS payments for dual-eligible beneficiaries may incentivize participation of practices that serve a disproportionate share of vulnerable populations. Although payer participation for the multi-payer model remains uncertain, the EOM may have implications for commercial APMs and shape the broader value-based care landscape even for payers that choose not to join the model.

Avalere has deep expertise with alternative payment model design and a proven history assisting a range of clients with analytics and research on the observed or anticipated impact of models, including the OCM, Radiation Oncology Model, and Accountable Care Organization models. To learn more about how Avalere can support you in understanding implications of the EOM design and payment methodology, connect with us.