Improving the Oncology Model – Successor to the Oncology Model of Care: What’s New | Blogs | The Health Care Act Today

Thanks to co-author Danny Costandi, a summer associate in Foley’s San Diego office, for his contributions to this post.

The Center for Medicare and Medicaid Innovation (CMMI) is launching a long-awaited new oncology model, the Enhancing Oncology Model (EOM). The EOM is the successor to the Oncology Care Model (OCM), which ended on June 30, 2020 after a five-year demonstration. EOM aligns with the goals of the Biden-Harris administration’s Cancer Moonshot Initiative, which seeks to improve the experience of people living with cancer, drive transformation in cancer care, and increase health equity while reducing Medicare costs.

Like the recently ended OCM, EOM is a voluntary model available to all Medicare-enrolled physician groups with at least one oncology physician or advanced practice provider that will run for five years beginning July 1, 2023. EOM encourages participants to adopt a value-based and patient-centered approach for Medicare beneficiaries receiving systemic chemotherapy over time and implement proactive care behaviors. Like other CMMI innovation models, such as primary care (PCF) and direct provider contracting (DPC), the Centers for Medicare & Medicaid Services (CMS) encourages physician groups treating underserved populations to apply. In addition, private payers and state Medicaid agencies are encouraged to comply with the EOM.

As noted below, EOM requirements are based on OCM requirements. Unlike OCM, all participants in EOM will be exposed to downside risk. Accordingly, we expect OCM practices that have received performance payments in the one-sided model or succeeded in the two-sided risk model in OCM will apply to participate in EOM.

All qualified physician groups can now apply to participate in the EOM until September 30, 2022. As with many other innovation models, approved applicants will elect to participate after receiving an agreement to participate from CMS.

EOM and OCM – Similarities and Differences

Like OCM, EOM will use six-month episodes of care and requirements for enhanced services, monthly payments, and performance-based payments based on the quality of services performed.

  • Pay per episode will drop from $160 per OCM to $70 per EOM.
  • EOM participants may elect to charge a monthly incremental payment of $70 for each beneficiary (and $30 more per month for dual eligible patients).

EOM participants can choose from two risk arrangements, both of which include a downside risk – moderate risk profile expected to qualify as an Alternative Payment Model (APM) under CMS’s Merit-Based Incentive Payment System (MIPS) and a more aggressive risk profile that will meet requirements such as MIPS APM and Advanced APM. Participants may switch between the two risk arrangements between performance years. OCM offers a unilateral risk agreement that qualifies as MIPS APM and a bilateral risk agreement that qualifies as Advanced APM.

However, MNI will have fewer qualified beneficiaries than OCM, but has greater potential for cost reduction. OCM included almost all beneficiaries receiving systemic chemotherapy or hormone therapy for all cancers. In contrast, EOM is limited to beneficiaries receiving systemic chemotherapy for seven types of cancer:

  • breast cancer;
  • chronic leukemia;
  • small bowel/colorectal cancer;
  • lung cancer;
  • lymphoma;
  • multiple myeloma; and
  • prostate cancer.

Like OCM, EOM will require participants to complete the following:

  • Offer 24/7 access to an appropriate clinician with real-time access to patient records;
  • Provide patient navigation;
  • Document a plan of care;
  • Use data to improve quality;
  • Familiarize yourself with quality measures (eg, patient experience, acute care utilization, symptom and toxicity management, psychosocial health management, palliative care management).

Unlike OCM, EOM will additionally require participants to screen for health-related social needs; report patient demographics (eg, race, ethnicity, language, gender); developing plans showing how participants will use evidence-based strategies to address health care gaps in their patient populations; and will slowly introduce patient-reported outcomes electronically. For the latter activities, the use of participant data for quality improvement, which will be continuously supported by feedback reports from CMS that will help the EOM to identify disparities among the patient population.

Similar to how OCM participants benefited from simplified telehealth and home care in the public health emergency waiver, CMS is waiving some Medicare payment requirements for EOM participants and expanding the toolbox to manage patient-centered care.

  • Improving telehealth benefits allows beneficiaries to visit from anywhere, rather than having to travel to a health facility.
  • The increase in post-discharge benefits allows for up to nine post-discharge home visits by support staff within 90 days of discharge under the general supervision (not direct) of a physician or other qualified practitioner.
  • Increasing the benefit of home visits for care management allows for home visits by support staff under the general supervision (not direct supervision) of a physician or other qualified practitioner prior to potential hospitalization.

Former OCM participants, along with practices that have withdrawn from OCM or joined other innovation models interested in participating in EOM, need to carefully consider whether and how they will adapt to successfully participate in the new model .

Foley is here to help you navigate the short and long term impacts of regulatory change. We have the resources to help you navigate these and other important legal considerations related to business operations and industry-specific issues. Please contact the authors, your Foley affiliate, or our healthcare practice group with any questions.

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