Enhancing Oncology Model Participation

On July 12, the Center for Medicare & Medicaid Innovation (CMMI) updated the list of Enhancing Oncology Model (EOM) participants in its first performance period (PP). EOM PP1 includes 44 participants and three payers. Overall, the EOM has fewer participants than the Oncology Care Model (OCM). A smaller participant group was expected given the streamlined list of included tumors, lower monthly enhancing oncology service (MEOS) payments, and mandated 2-sided risk.

The OCM, the EOM’s predecessor, began in July 2016 with 190 participants; 122 remained active through the end of OCM (June 30, 2022). Initially, CMMI published a list of 67 participants, however, this list did not reflect participants that terminated from the Model prior to the July 1 start date. Notably, the practices sites associated with American Oncology Partners include 22 practices that are members of the American Oncology Network.  Avalere compared EOM and OCM participants’ affiliations and geographic characteristics (Table 1). Of the 44 participants, 23 are community-based and 30 participated in the OCM.

Note, the characteristics in Table 1 reflect the participants active in the EOM on July 1, 2023 and active in the OCM as of January 2, 2022.
* CMMI states that 122 participants were active in the OCM as of June 30, 2022. However, CMMI materials only include a list of the 126 participants active as of January 2, 2022.
** Counts for census regions exceed the total participant count because American Oncology Partners has practices in three census regions.

OCM Evaluation Report Findings

On May 31, CMMI released the OCM Evaluation Report for PP1–9. EOM participants will likely look to this report for lessons learned and strategies for success. Findings may inform EOM participants’ care redesign activities as they face a lower MEOS payment and mandatory 2-sided risk.

CMMI reported a relative reduction in OCM episodes payments of $499 over the first 4.5 years of the OCM and highlighted several drivers of cost savings in the latest evaluation report.

Reduced Episode Payments for Certain Higher-Risk Cancer Types: OCM led to a relative reduction in total episode payments for four higher-risk cancer types: lymphoma, colorectal cancer, high-risk breast cancer, and lung cancer. All four of these cancer types are included in the EOM.

Lower Part A and B Payments: Over half of the reduction in total episode payments was in Part B payments; these were predominantly non-chemotherapy drug payments, with no OCM impacts on payments for Part B chemotherapy drugs. Reductions in Part A payments made up 30% of the reduction in total episode payments due to reductions in intensive care unit admissions, readmissions, and emergency department visits leading to inpatient stays.

Greater Use of Biosimilars: CMMI evaluated the use of three biosimilar cancer treatments following their availability in 2019. CMMI reported biosimilars use among OCM episodes was 20–40% greater than comparison episodes.

No Impact to Health Equity: The OCM design did not include elements focused on improving health equity, and the evaluation report did not identify changes in any historically underserved populations. Unlike the OCM, the EOM provides additional MEOS payments for dual-eligible beneficiaries and requires participants to screen patients for health-related social needs and develop health equity plans.

Despite the relative reduction in total episode payments ($499), CMMI reported net losses of over $500M to Medicare after accounting for MEOS and performance-based payments in the first four years of the OCM.

Preparing for the EOM

The EOM began July 1 with 44 participants. Over one-third of the participants also participated in the OCM and comprise both community and health-system practices. Former OCM participants will build on their OCM strategies, while new EOM participants may rely more on the findings of the OCM report and case studies. New EOM participants will not have the advantage of prior experience and will need to implement multiple cost-saving strategies immediately given mandatory 2-sided risk. Participant adaptation to 2-sided risk may impact prescribing and other care coordination and decision-making patterns and catalyze trends in future value-based care models.

Avalere has partnered with key stakeholders in oncology to assess previous OCM and future EOM practice performance. To better understand practice performance, including cancer-specific insights, connect with us.