This week, our In Focus section reviews the new Center for Medicare and Medicaid Innovation (CMMI) model named the Enhancing Oncology Model (EOM), released on June 27, 2022, by the Centers for Medicare & Medicaid Services (CMS). This new physician specialty model builds off the previously implemented Oncology Care Model (OCM). The EOM incentivizes the coordination of care and the improvement of care quality for Medicare patients undergoing cancer treatment. The model also seeks to reduce Medicare fee-for-service spending for oncology services, because oncology services are an area of high spending within the Medicare program. As a part of the EOM model participating physician practices will be held accountable for financial and performance targets during six-month episodes of care for systemic chemotherapy administration to patients with common cancer types. The EOM will run for five years beginning on July 1, 2023. Applications to EOM are currently open and will close on September 30, 2022.
CMS indicated that EOM supports President Biden’s Cancer Moonshot initiative to improve the experience of people and their families living with and surviving cancer. EOM aligns with the Cancer Moonshot pillars and priorities of supporting patients, caregivers, and survivors, learning from all patients, targeting the right treatments for the right patients, and addressing inequities.
Consistent with CMS priorities, EOM also has a strong health equity focus and oncology practices who care for underserved beneficiaries are encouraged to apply.
Design of EOM
EOM is built off the foundation of OCM which ran from July 1, 2016, through June 30, 2022. CMS previously solicited feedback from the oncology community and other interested stakeholders on an OCM successor model. Those lessons plus an alignment with CMMI’s strategy refresh priorities of moving to total cost of care accountable models and making cancer care more affordable and accessible created the foundations for the design of the model.
Under EOM, participating Physician Group Practices (PGPs) will take on accountability for their patients’ health care quality and for total Medicare Parts A and B and certain Part D spending during six-month episodes of care. Eligible Medicare patients are those with certain cancers (breast cancer, chronic leukemia, small intestine/colorectal cancer, lung cancer, lymphoma, multiple myeloma, and prostate cancer) receiving chemotherapy treatment.
- Participating practices may bill for a Monthly Enhanced Oncology Services (MEOS) ($70 per month) payment for Enhanced Services provided to eligible beneficiaries. The MEOS payment will be higher ($100 per month) for beneficiaries dually eligible for Medicare and Medicaid.
- Enhanced services are
- Provide EOM beneficiaries 24/7 access to an appropriate clinician who has real-time access to the EOM participant’s medical records.
- Provide patient navigation, as appropriate, to EOM beneficiaries
- Document a care plan for each EOM beneficiary that contains the 13 components in the Institute of Medicine (IOM) Care Management Plan applicable to the EOM beneficiary
- Treat EOM beneficiaries with therapies in a manner consistent with nationally recognized guidelines
- Identify EOM beneficiary social needs using a health-related social needs screening tool
- Gradual implementation of electronic Patient Reported Outcomes (ePROs)
- Participants will be required to take on downside financial risk from the start of the model (with the potential to owe CMS a performance-based recoupment). If participants successfully meet quality and savings targets, they will have the opportunity to earn a retrospective performance-based payment (PBP). These amounts will be based on actual practice performance.
- CMS has not yet specified the quality measures for this model. Instead, the application says the EOM quality strategy will focus on the following domains: patient experience, avoidable acute care utilization, management of symptoms toxicity, management of psychosocial health, and management of end-of-life care. CMS will prioritize measures that; reflect national priorities for quality improvement and patient-centered care, are outcomes-based measures (including those collected from patients), minimize EOM participant burden where possible, and align with CMS and Innovation Center quality strategy.
- Health equity provisions of the EOM include requiring oncology practices to screen for health-related social needs (HRSNs), CMS providing data reports on patient expenditures and utilization for to help health care professionals identify and address health disparities, and CMS increasing reimbursement for the provision of Enhanced Services to patients who are dually eligible for Medicare and Medicaid.
- CMS also will issue payment waivers and benefit enhancements to provide additional flexibility to practices in the way they deliver care to patients. Expected enhancements include telehealth, post-discharge enhancements, and care management home visits.
CMS has designed EOM as a multi-payer model. Medicare Advantage plans, state Medicaid plans and other payers are invited to apply to enter into a Memorandum of Understanding with CMS to align on incentives for oncologists to improve care to their patients and increase participation in value-based care arrangements.
CMS intends to release additional information about EOM payment methodologies later this summer. CMS also will be hosting several upcoming webinars regarding the payment methodology, quality strategy and general application support office hours before the application due date of September 30, 2022. CMS intends to select participants later this year or early next year and will implement the EOM on July 1, 2023.
For more information about this new model and how providers and payers can apply to it, please contact our Medicare team who have knowledge in CMS and its value-based payment programs, Amy Bassano (HMA Managing Director, Medicare) ([email protected]), Julie Faulhaber (HMA Managing Director, Medicare) ( [email protected]) Andrea Maresca (HMA Principal) ([email protected]), or Zach Gaumer (HMA Principal) ([email protected]). To access the EOM application and other model materials, you may visit https://innovation.cms.gov/innovation-models/enhancing-oncology-model.