OCM Successor Puts Focus on Equity in Cancer Care—With Fewer Dollars for Services

Days before it expired, CMS announced a replacement for the Oncology Care Model (OCM) that officials say will put more focus on health equity—but with less money to offer services that physicians say have improved patients’ lives.

The OCM, launched in 2016, ended on June 30 amid calls for an extension and praise from oncologists who say they will never return to the old way of delivering care. Despite the OCM’s flaws, practice leaders say they’ve learned a lot, which they see reflected in the successor, the Enhancing Oncology Model (EOM), announced on June 27.^1,2

However, the EOM will not start until July 2023, creating a yearlong gap for practices that took part in the OCM and relied on it to report quality measures to Medicare. Now, these practices will be required to report through the Merit-based Incentive Payment System (MIPS), which serves as a fallback option for any practice that receives Medicare payments but does not participate in an advanced alternative payment model (APM). A 2015 law overhauling Medicare reimbursement requires quality reporting under either MIPS or an APM. ^3,4

Early reviews of the EOM are mixed. Physicians, including some who spoke with Evidence-Based Oncology™ (EBO) say the Center for Medicare & Medicaid Innovation (CMMI) made several improvements that will make the new model easier to administer than the OCM. But there’s a downside: Monthly payments that OCM practices used to fund new services—such as patient navigation—will be cut 56% for each Medicare patient and 37% for those receiving both Medicare and Medicaid.²

In its announcement, the Biden administration addressed complaints that the OCM fell short in addressing disparities in treatment and outcomes, and that it failed to reward practices that cared for the poorest patients. The EOM comes with significant new reporting requirements, which will track demographic information and how well practices deliver care when patients have “health-related social needs.”

“There are stark inequities in the ability of people with cancer across race, gender, region, and income to access cancer screening, diagnostics, and treatment,” said CMS Administrator Chiquita Brooks-LaSure. “CMS is working to advance President Biden’s Cancer Moonshot goals by helping Medicare cancer patients better navigate a challenging and often overwhelming journey. The Enhancing Oncology Model will incentivize participating oncology practices—including those in rural and underserved areas—to improve the provision of high quality, coordinated care that addresses patients’ social needs and improves patient and caregiver support.”¹

When the EOM was unveiled, Ted Okon, MBA, executive director of the Community Oncology Alliance (COA), said the group was “disappointed” with both the plan to cut monthly payments and with the yearlong gap between the 2 models. “During this time, practices will have to shoulder the extensive investments and operational changes put in place to benefit patients without reimbursement,” he said.⁵

In the weeks that followed, Okon reacted strongly to additional CMS proposals that will cut the Medicare conversion factor by 4.42%, along with “additional cuts to oncology, imaging, and radiation.”⁶ Finally, COA blasted a separate plan that would halt reforms to the 340B drug discount program, which community oncologists say have pushed too many independent practices into mergers or buyouts from hospitals.⁷

The net result, some community oncologists say, is that the EOM could be a tough sell to practices that lack experience in delivering value-based care. Larger community oncology networks that had mastered the OCM in its final years will still have to navigate the financial pieces with care. As Okon stated, COA fully supports screening for social needs and collecting patient-reported data; however, “it seems unfair to burden practices with more work but pay less for it.”

Stephen Schleicher, MD, MBA, the chief medical officer for Tennessee Oncology, praised CMMI for building a new model that clearly reflects lessons from the OCM and feedback from physicians. But Schleicher said that cuts to Monthly Enhanced Oncology Services (MEOS) payments, which are the more predictable of 2 Medicare reimbursement streams, could put practice transformation beyond the reach of those who most need to embrace it. Even practices that were not part of OCM must take on some downside risk right away. This is a change from OCM, which let practices learn the model before taking on 2-sided risk.

“Tennessee Oncology is excited for this next model. We want to understand more, but it will take a lot for us not to participate—to not want to keep innovating with a partner like Medicare,” Schleicher said. “But if you’re a practice that hasn’t already invested in OCM, now you have a smaller population, lower MEOS [payments], and you have to do 2-sided risk—and one option might not get you out of MIPS.

“It’s going to be hard to get the practices that really need this to want to voluntarily participate,” Schleicher stated. “I’m afraid we’re going to get some selection bias on who’s excited to participate.”

Lessons From the OCM
The OCM, first proposed in 2015, created financial incentives for providers who offered a more complete set of cancer care services, with a focus on care coordination.⁸ The goal was to reward those who offered appropriate care—not necessarily the most expensive care. The model had several defining features:

• It required participating practices to offer several enhanced services, including 24/7 access to the patient’s medical records, use of a certified electronic health record, patient navigation, a documented care plan including survivorship care, and treatment that followed clinical guidelines.
• Practices had incentives to keep patients out of the hospital and the emergency department (ED). Using technology, many developed sophisticated triage systems to respond to patient calls. Practice schedules were revamped to accommodate same-day, evening, or weekend appointments. More attention was paid to services, such as nutrition, that help keep patients out of the ED.
• Practices had to develop systems for tracking and reporting patient quality data, which were needed for reimbursement.
• Reimbursement through the OCM came through 2 streams:
  Practices received monthly MEOS payments based on episodes of care.
  Performance-based payments were made retroactively, based on measures of a practice’s ability to deliver quality care and achieve savings. Over time, practices were encouraged to take on “downside” risk in this second stream—meaning they would owe Medicare money if they fell short of benchmarks.

Leading oncology practices have said that the OCM, while far from perfect, propelled them forward to make strides in practice transformation that would have been harder to achieve without Medicare’s leadership. Many commercial payers have developed versions of the OCM, and few can envision returning to care without services such as patient navigation or care planning.

Both sides improved over time. A chief criticism of the OCM is that it failed to save enough money for Medicare.⁹ Large community oncology networks dispute this claim, arguing that the bad reviews were based upon outcomes during the model’s early years, before practices developed efficiencies to administer it well.

During a recent webinar, leaders from The US Oncology Network said that the OCM had brought $240 million in savings for Medicare going into 2020, and the network had seen a 24% drop in ED visits and a 37% decrease in hospitalizations (See Cover for related article).¹⁰

At the same time, CMMI tweaked the model to address complaints that payment structures were not keeping pace with drug development, shortchanging those practices that hewed to guideline-directed care.

What’s New Under the EOM
Physicians have acknowledged that the next incarnation of the model should address health equity, and Kashyap Patel, MD, president of COA, supported this change when CMMI announced its “refresh” of APMs in 2021. “So far, models have focused on cost, quality, and patient experience. [Adding] equity as one of the factors is a welcome change,” Patel said.¹¹

The EOM is proposed to run for 5 years through June 2028. It retains some key elements of the OCM; notably, it will be voluntary, not mandatory. It retains the basic structure, with 6-month care episodes and requirements for enhanced services, as well as the 2 reimbursement streams: monthly payments tied to episodes of care, and performance-based payments based on quality measures and demonstrated savings.

However, there are some important differences. Oncologists who spoke with EBO praised CMMI for narrowing the scope of the EOM to reward those practices that design systems for true practice transformation, without penalizing practices for events beyond the oncologists’ control.

Limiting number of cancer types. In the biggest change, the EOM applies only to Medicare patients undergoing chemotherapy for common cancer types: breast cancer, chronic leukemia, lung cancer, lymphoma, multiple myeloma, prostate cancer, and small intestine/colorectal cancer. In contrast, the OCM covered nearly all types of cancer. Oncologists who spoke with EBO praised this decision, because it’s less likely that an outlier case—one with high costs and fewer similar cases for comparison—will throw off the practice’s overall performance data.

“If you have patients with the 7 most common cancers, you’re really focused on how you can take better care of those patients—and how you can transform the clinical care of those patients,” Edward J. Licitra, MD, PhD, chairman and CEO of Astera Health Partners, said in an interview. “By choosing the 7 most common cancers, it actually creates a much larger pool of patients. So, this controls the outlier phenomenon.”

If practices are evaluated on how they manage common cancer types, Licitra said, they can concentrate on selecting the right therapies, creating proper regimens, and enrolling patients in the right clinical trials. “You can really have a much more focused approach to taking care of patients, improving their experience, and controlling costs,” he said.

Certain low-risk patients excluded. The EOM will not cover patients with low-risk breast and low-risk prostate cancer. Schleicher explained that these conditions are typically treated with hormonal therapy, and that the oncologist can do little from a care management standpoint to affect overall care costs. Under the OCM, a low-risk cancer patient who had a heart attack or joint replacement—and received that care elsewhere—could hurt the oncology practice’s performance.

“I think this is an appropriate interpretation of OCM feedback reports,” Schleicher said.

Attribution. The EOM attempts to resolve a top physician complaint: When a patient sees many specialists, which practice includes that person in their roster of care episodes? Under the new program, if no practice provides 25% of all cancer-related evaluation and management (E/M) services for a patient during a 6-month episode, then the practice receiving attribution for that patient will have provided the plurality of E/M episodes.^2,12

Patient-reported outcomes. As expected, the EOM will add requirements for practices to collect electronic patient-reported outcomes. And in a consumer-friendly move, no co-payments will be required for patients to receive enhanced services.

Taking on 2-sided risk. Risk arrangements will start with a benchmark, which is an estimated amount of cost for all episodes in a 6-month period. All practices enrolled in the EOM will be required to take on some “downside” risk; however, the program offers 2 different options:

Risk Arrangement 1, a lower-risk tier, will offer a limited level of performance-based reimbursement while limiting losses. According to information from CMMI, the stop loss will be capped at 2% of the benchmark, while the stop gain will be capped at 4%.

Risk Arrangement 2, a higher-risk tier, offers greater reimbursement potential with more risk of repaying Medicare if benchmarks are not met; stop loss can reach 6% of benchmark, while the stop gain can reach 12%.
The first tier may appear to be the best option for practices that are less experienced in value-based care, but there’s a catch: The lower-risk tier will not qualify as an APM, and these practices will still have to report under MIPS.¹²

Addressing Health Equity in Cancer Care
As expected, a major focus of the EOM is addressing health equity: The model will include additional payments to oncology practices for patients who qualify for both Medicare and Medicaid. Practices must report demographic data and outline plans to address health equity.
Oncologists and practice leaders were surprised that the base MEOS payments will drop from $160 to $70. For dually eligible patients, MEOS payments will be $100 per month.2,12 And, Schleicher said, the extra $30 for Medicaid patients does not apply to the patient’s total cost of care, which will aid practices when they measure savings.

Milena Sullivan, managing director for Avalere Health, explained in an email how the EOM will address patients who are “dually eligible.” These beneficiaries are enrolled in both Medicare and Medicaid, “with Medicare serving as the primary payer, while Medicaid wraps around by providing assistance with premiums and cost sharing.” As Sullivan explained, the EOM would recognize that these patients are often sicker and require more complex care; they represent 19% of enrollees, but 34% of spending.

Schleicher said the MEOS payments are “crucial” for practices’ ability to deliver holistic care, so any cut presents a challenge. Already, many OCM practices have worked with commercial payers to extend enhanced services to every patient. Losing MEOS revenue will mean cost shifts for some practices; for others, services may be cut.

Practices have until September 30 to apply for the EOM, and it remains to be seen if the proposed reimbursement scheme will attract new participants. Already, CMS has seen the faltering of one highly touted evidence-based model—the Medicare Diabetes Prevention Program—when too few providers enrolled. Diabetes education advocates warned that this would happen because the reimbursement schedule was inadequate, given administrative costs.¹³

“Community oncology practices are fully committed to positive, patient-centered improvement of cancer care and look forward to supporting CMMI and practices to make the EOM a success,” Okon said. “The goals of the EOM are ones we wholeheartedly support, especially related to improving cancer health equity, electronic patient-reported outcomes, enhanced access to cancer screenings.” 

References
1. Biden administration announces new model to improve cancer care for Medicare patients. News release. CMS; June 27, 2022. Accessed June 27, 2022. https://go.cms.gov/3v3Ty0a
2. Enhancing Oncology Model. News release. CMS; June 27, 2022. Accessed June 27, 2022. https://www.cms.gov/newsroom/fact-sheets/enhancing-oncology-model
3. Quality Payment Program. CMS. Accessed July 20, 2022.
4. Avalere Health. A practical guide to navigating MACRA. Community Oncology Alliance. April 12, 2018. Accessed July 18, 2022. https://bit.ly/3cvljbx
5. Okon T. Community Oncology Alliance statement on the Enhancing Oncology Model. News release. Community Oncology Alliance; June 27, 2022. Accessed June 27, 2022. https://bit.ly/3PpdQJL
6. Okon T. Community Oncology Alliance statement on proposed 2023 Medicare Physician Fee Schedule. News release. Community Oncology Alliance; July 8, 2022. Accessed July 18, 2022. https://bit.ly/3RNFi5C
7. Okon T. Community Oncology Alliance statement on proposed 2023 Hospital Outpatient Prospective Payment rule. News release. Community Oncology Alliance; July 18, 2022. Accessed July 18, 2022. https://bit.ly/3PxGo3w
8. Oncology Care Model. CMS. Updated July 20, 2022. Accessed July 25, 2022. https://innovation.cms.gov/innovation-models/oncology-care
9. Hassol A, West N, News-Adeyi G, et al. Evaluation of the Oncology Care Model: performance periods 1-5. CMS. January 2021. Accessed November 16, 2021. https://innovation.cms.gov/data-and-reports/2021/ocm-evaluation-pp1-5
10. Caffrey M. Value-based care will “continue to evolve” even if OCM expires. Am J Manag Care. 2022;28(4 Spec No):SP208-SP209. doi:10.37765/ajmc.2022.89177
11. Melillo G. With no replacement for OCM on the horizon, oncology practices ask: what now? Am J Manag Care. 2021;27(9 Spec No):SP390. doi:10.37765/ajmc.2021.88800
12. Strawbridge L, Cavanagh H, Chong A, Ela E. Enhancing Oncology Model: EOM overview webinar. CMS. June 30, 2022. Accessed July 18, 2022. https://innovation.cms.gov/media/document/eom-model-overview-slides
13. Ritchie ND, Sauder KA, Gritz RM. Medicare Diabetes Prevention Program: where are the suppliers? Am J Manag Care. 2020;26(6):e198-e201. doi:10.37765/ajmc.2020.43496