Enhancing Oncology Model
The Centers for Medicare & Medicaid Service’s (CMS) Innovation Center’s new, voluntary Enhancing Oncology Model (EOM) is intended to transform care for cancer patients, reduce spending, and improve quality of care. It is designed to test how best to place cancer patients at the center of the care team that provides high-value, equitable, evidence-based care. EOM aims to improve care coordination, quality, and health outcomes for patients while also holding oncology practices accountable for total costs of care to make cancer care more affordable and accessible for beneficiaries and Medicare, which are key priorities described in the CMS Innovation Center’s strategy refresh.
EOM aligns with President Biden’s Cancer Moonshot pillars and priorities of supporting patients, caregivers, and survivors, and addressing inequities. On February 2, 2022, the Biden-Harris Administration reignited the Cancer Moonshot effort by setting a goal of reducing the cancer death rate by at least 50% over the next 25 years and improving the experience of people and their families living with and surviving cancer.
EOM also includes a focus on improving health equity, another top priority for the CMS Innovation Center. CMS encourages oncology practices who care for underserved beneficiaries to apply. The health equity strategy for EOM will include requiring oncology practices to screen for health-related social needs (HRSNs), introducing data reports on expenditure and utilization patterns of their patient population to help health care professionals identify and address health disparities, and offering an additional payment for the provision of Enhanced Services to patients who are dually eligible for Medicare and Medicaid. These additional payments for dually eligible patients will not be included in practices’ total cost of care responsibility. EOM participants will ask patients to routinely report their symptoms in order to encourage better communication and a more proactive care response, and EOM participants will be required to submit plans outlining how they will promote health equity.
The model’s design incorporates many of the lessons that CMS learned from the Oncology Care Model (OCM) (tested from July 1, 2016 – June 30, 2022) and feedback from the oncology community, including to OCM participants, patient advocacy groups, oncology professional associations, and others. EOM will launch on July 1, 2023, for a five-year test. Like OCM before it, EOM will be a multi-payer model to promote a consistent approach across payers and EOM participants’ patient population.
The application submission period opens June 27 2022 and closes September 30, 2022. The Request for Applications (RFA) is available on the EOM website at https://innovation.cms.gov/innovation-models/enhancing-oncology-model. The model performance period will begin in July 2023 and end in June 2028.
Purpose of the Model
Section1115A of the Social Security Act (the Act) (added by Section 3021 of the Affordable Care Act) (42 USC § 1315a) established the Innovation Center to test innovative payment and service delivery models that have the potential to reduce Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) expenditures while preserving or enhancing the quality of beneficiaries’ care. Under traditional Medicare fee-for-service (FFS), oncology providers and suppliers generally receive separate payments for each item or service furnished to a beneficiary during the course of their cancer treatment. This creates a financial incentive for some providers and suppliers to increase the volume of items and services or prescribe high-cost, but not necessarily higher value drugs. These actions may adversely affect the beneficiary with cancer and the Medicare program.
In addition, traditionally, cancer care has focused on treating the disease and not the person, resulting in fragmented care (e.g., the oncologist’s focus on the patient is typically limited to the time when they are in an exam room with limited coordination with other providers involved in a patient’s care). Similar to OCM, EOM will focus on value-based, patient-centered care for cancer patients undergoing systemic chemotherapy over time, in six-month episodes of care. Under EOM, participants will be incentivized to consider the whole patient and engage with them proactively, during and between appointments. The design of EOM builds on the lessons learned in OCM, and incorporates key learnings from the OCM experience.
EOM aligns payment incentives with care quality, encouraging EOM participants to improve quality by implementing participant redesign activities. This includes some activities that were successfully implemented in OCM, such as patient navigation and care planning, and some that are new to EOM, including the gradual implementation of electronic Patient-Reported Outcomes (ePROs) and activities that promote health equity.
How EOM Supports Cancer Patients
The central goal of EOM is to better support patients and improve their care experience.
Patients whose health care providers are participating in EOM may communicate better with their oncologist and care team in between appointments and be able to more easily reach them with questions. Additionally, patients may receive enhanced, patient-focused services, such as 24/7 access to an appropriate clinician with real-time access to patient medical records; patient navigation services (e.g., facilitating linkages to follow-up and/or support services, providing access to clinical trials as medically appropriate, etc.); and detailed care plans involving discussions with patients about prognosis, treatment options, symptom management, quality of life, and psychosocial health needs, among other topics. For participants’ delivery of Enhanced, Services, patients will not be responsible for cost sharing for any portion of the new EOM payment.
Patients will have an opportunity to provide feedback about their overall cancer care experience and health outcomes, such as those related to their symptoms, physical functioning, and behavioral health, through electronic devices. EOM participants will also screen patients for health-related social needs (HRSNs), such as lack of proper nutrition during chemotherapy or limited access to transportation to infusion appointments, which can contribute to and/or exacerbate cancer health disparities. The data sharing requirements between EOM participants and CMS will also allow for a better understanding of patients’ information to address inequities and learn more about targeting the right treatments.
Patients retain their freedom to choose any provider or supplier, and may also choose for their data not to be shared with EOM participants. If a patient or their caregiver feels care has been compromised, or has concerns about EOM, the Innovation Center has a model liaison that is a part of the Medicare Beneficiary Ombudsman team in the Office of Hearings and Inquiries. The model liaison can be reached through 1-800-MEDICARE or they may contact their Quality Improvement Organization (QIO), here.
Key Elements of the EOM Design
Under EOM, participating Physician Group Practices (PGPs) will take on accountability for their patients’ health care quality and for total spending during six-month episodes of care for Medicare patients with certain cancers.
- CMS will give participants the option to bill for a Monthly Enhanced Oncology Services (MEOS) payment for Enhanced Services provided to eligible beneficiaries. The MEOS payment will be higher for beneficiaries dually eligible for Medicare and Medicaid.
- EOM participants will have the opportunity to earn a retrospective performance-based payment (PBP) based on quality and savings. Participants will be required to take on downside risk from the start of the model (with the potential to owe CMS a performance-based recoupment).
- EOM participants will be required to implement participant redesign activities, including 24/7 access to care, patient navigation, care planning, use of evidence-based guidelines, use of electronic Patient Reported Outcomes (ePROs), screening for health-related social needs, use of data for quality improvement, and use of certified electronic health record technology.
- EOM will focus on beneficiaries receiving systemic chemotherapy (that is, not beneficiaries receiving hormonal therapy only) for seven cancer types: breast cancer, chronic leukemia, small intestine/colorectal cancer, lung cancer, lymphoma, multiple myeloma, and prostate cancer.
Model Participants and Locations
The model will be national in scope. Oncology PGPs located anywhere in the United States are encouraged to apply to participate. Similar to OCM, EOM will be a multi-payer model. Private payers, Medicare Advantage plans, and state Medicaid agencies are invited to apply for the model and to enter into a Memorandum of Understanding (MOU) with CMS. There will be two parts of EOM: one operated by CMS for Medicare FFS, and another operated by EOM payers for their enrollees who are patients of an EOM participant. This will encourage PGPs to have the same approach for both Traditional Medicare beneficiaries and patients with other forms of health insurance.
Quality Payment Program (QPP)
EOM includes two risk arrangements with differing levels of downside risk. Both EOM risk arrangements are expected to qualify as a Merit-based Incentive Payment System (MIPS) Alternative Payment Model (APM) under the QPP beginning in July 2023. The risk arrangement with increased downside risk (EOM’s Risk Arrangement 2) is expected to meet the criteria under 42 CFR § 414.1415 to be an Advanced APM under the QPP beginning in July 2023. Advanced APM participation allows a clinician the opportunity to achieve Qualifying APM Participant (QP) status and be excluded from the MIPS reporting requirements and payment adjustments. Clinicians in an Advanced APM that do not achieve QP status will be subject to the MIPS reporting requirements and payment adjustments. For more information see the QPP website, here https://qpp.cms.gov/ and the RFA on the EOM website, here: https://innovation.cms.gov/innovation-models/enhancing-oncology-model.
For more information, visit: https://innovation.cms.gov/innovation-models/enhancing-oncology-model.