Vielen Dank an den Mitautor Danny Costandy, Sommerpraktikant in der Kanzlei Foley in San Diego, für seine Beiträge zu diesem Beitrag.
The Center for Medicare and Medicaid Innovation (CMMI) is launching a long awaited new oncology model, the Enhancing Oncology Model (EOM). EOM is a successor to the Oncology Care Model (OCM), which ended June 30, 2022 after a five-year demonstration. EOM aligns with the objectives of the Biden-Harris Administration’s Cancer Moonshot Initiative, which seeks to improve the experience of people living with cancer, drive transformation in oncology care and advance health equity, while reducing Medicare spending.
Similar to 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 on July 1, 2023. EOM incentivizes participants to adopt a value-based and patient-centered approach for Medicare fee-for-service beneficiaries receiving systematic chemotherapy over time and implement proactive care behaviors. Similar with other CMMI innovation models like primary care first (PCF) and direct provider contracting (DPC), the Centers for Medicare & Medicaid Services (CMS) is encouraging physician groups treating underserved populations to apply. Further, private payers and state Medicaid agencies are encouraged to align with EOM.
As noted below, EOM requirements build upon OCM requirements. Unlike OCM, all EOM participants will be exposed to down-side risk. Accordingly, we anticipate OCM practices that received performance payments in the one-sided model or succeeded under the two-side risk model in OCM will apply to participate in EOM.
All qualifying physician groups can now apply to participate in EOM through September 30, 2022. As with many other innovation models, approved applicants will elect to participate after receiving a participation agreement from CMS.
EOM and OCM – Similarities and Differences
Similar to OCM, EOM will employ six-month care episodes and requirements for enhanced services, monthly payments, and performance-based payments based on quality of services performed.
- Episode-based payment will drop from the OCM’s $160 to the EOM’s $70.
- Participants in EOM can choose to bill for a monthly enhanced payment of $70 for each beneficiary (and $30 more per month for dual-eligible patients).
EOM participants can select from two risk arrangements that both involve downside risk – a moderate risk profile that is expected to qualify as a CMS Merit-based Incentive Payment System (MIPS) alternative payment model (APM) and a more aggressive risk profile that will qualify as a MIPS APM and an Advanced APM. Participants may switch between the two risk arrangements between performance years. OCM offered a one-side risk arrangement that qualified as a MIPS APM and a two-sided risk arrangement that qualified as an Advanced APM.
However, EOM will have fewer qualifying beneficiaries than OCM but have a greater potential for cost-reduction. OCM included nearly all beneficiaries receiving systemic chemotherapy or hormonal therapy for all cancer types. In contrast, EOM is limited to beneficiaries receiving systemic chemotherapy for seven cancer types:
- breast cancer;
- chronic leukemia;
- small intestine/colorectal cancer;
- lung cancer;
- lymphoma;
- multiple myeloma; and
- prostate cancer.
Similar to OCM, EOM will require participants to implement the following:
- Offer 24/7 access to an appropriate clinician with real-time access to patient records;
- Provide patient navigation;
- Document a care of plan;
- Utilize data for quality improvement;
- Meet quality measures (e.g., patient experience, acute care utilization, symptom and toxicity management, management of psychosocial health, palliative care management).
Unlike OCM, EOM will additionally require participants to screen for health-related social needs; report patient demographic data (e.g., race, ethnicity, language, gender identify); develop plans showing how participants will use evidence-based strategies to address health equity gaps in their patient populations; and will slowly implement electronic patient reported outcomes. For the latter activities, participants’ use of data for quality improvements which will be continuously supported by feedback reports from CMS that will help EOM identify disparities among its patient population.
Similar to how OCM participants benefited from relaxed telehealth and home-based care under the Public Health Emergency waivers, CMS is waiving certain Medicare payment requirements for EOM participants and expanding their patient-centered care management toolbox.
- Telehealth benefit enhancement permits telehealth visit from any location to beneficiaries instead of requiring travel to a health care facility.
- Post-discharge benefit enhancement permits up to nine post-discharge home visits by auxiliary staff within 90 days of discharge under general supervision (not direct supervision) of a physician or other qualified practitioner.
- Care management home visit benefit enhancement permits home visits by auxiliary staff under general supervision (not direct supervision) of a physician or other qualified practitioner in advance of potential hospitalization.
Former OCM participants, along with practices who sat out participation in OCM or joined other innovation models, interested in participation in EOM, should carefully assess if and how they will adapt to successfully participate in the new model.
Foley is here to help you address the short and the long term impacts in the wake of regulatory changes. We have the resources to help you navigate these and other important legal considerations related to business operations and industry-specific issues. Please reach out the authors, your Foley relationship partner, or to our Health Care Practice Group with any questions.
