Stakeholder Summit Covers the Details of the EOM in Everyday Practice

Does the Enhancing Oncology Model (EOM), proposed as the successor to Medicare’s first alternative payment model in cancer care, have enough incentives to draw small practices into value-based care? Or will this new model, which draws on the Oncology Care Model (OCM), scare off practices that would prefer an on-ramp before facing 2-sided risk?

On November 1, 2022, The American Journal of Managed Care® (AJMC®) welcomed 4 experts to its headquarters in Cranbury, New Jersey, for a Stakeholders’ Summit: Putting the Enhancing Oncology Model Into Practice.

As the Center for Medicare and Medicaid Innovation (CMMI) reviews applications from practices that would like to start the model on July 1, 2023, AJMC® sought to hear from oncology leaders with direct experience in implementing both the OCM and commercial value-based models in community practices.

Stuart Staggs, MSIE, senior director for strategic programs, The US Oncology Network, served as moderator for the discussion, which featured these panelists:

• Stephen M. Schleicher, MD, MBA, chief medical officer of Tennessee Oncology, a part of the OneOncology network;
• Kashyap Patel, MD, CEO of Carolina Blood and Cancer Care Associates and president of the Community Oncology Alliance (COA); and
• Stephen “Fred” Divers, MD, chief medical officer of the American Oncology Network (AON) and a medical oncologist at Genesis Cancer and Blood Institute of Arkansas.

Staggs started the discussion by revisiting the OCM, which began in 2016 and ended on June 30, 2022, having been extended for 1 year due to the COVID-19 pandemic. Under the model, practices were evaluated in 6-month performance periods, based on their ability to perform well on quality measures and save Medicare money. Evaluations that looked at early performance periods found that the OCM did not save money, but as the experts taking part in the AJMC® discussion noted, that finding was not uniform—some practices mastered the model and saved more money as they went along.

To help practices implement practice transformation steps—such as patient navigation, 24/7 access to medical records, and technology innovations to schedule same-day appointments—practices received payments of $160 per patient per month during treatment. Payments for Monthly Enhanced Oncology Services (MEOS) will be cut to $70 under the EOM, with an extra $30 for patients who also receive Medicaid. The extra $30 does not count toward a patient’s total cost of care.

Staggs asked how practices might have reacted if CMMI had not offered a successor to the OCM.

“The OCM was a first blueprint, an architectural drawing of translating the concept of the CMMI model into real action,” Patel said. Practices invested in the model, hiring staff and making other changes, “in good faith” to enhance the patient experience and reduce the cost of care. The EOM is not perfect, but without something like it, “practices would have been disappointed,” he said.

Schleicher agreed, calling the OCM “a very useful pilot” that offered resources to practices so they could invest in transformation. He emphasized that some practices were quite successful even if overall evaluations found that the OCM did not save money—and added that from a quality perspective, the difference was huge. “It would be very detrimental not to continue this momentum that our practices [in OneOncology] and many others have had,” he said.

“One of the keys of the OCM and EOM is really trying to keep the patient at the center [of the equation],” Divers said. In practices that used the resources to create additional patient touch points, patient experience has dramatically improved. “We obviously didn’t want to see that go away,” he said, and AON practices are working to keep the additional staffing in place, despite the yearlong gap between models without the MEOS payments.

Staggs asked what it was like to work with CMMI over the years that the OCM was in place, compared with the relative surprise that EOM represented. Divers said the EOM did come “out of the blue,” and practices await specifics on reporting requirements. Schleicher and Patel agreed, but they noted the competing priorities at CMS; they remain hopeful that there will be opportunities to make changes over time, as was the case with the OCM.

The goal, Divers said, should be to get the right therapy for the patient. Practices will find value in the EOM if it generates data that can be used with an electronic health record to help practices match each patient with the right treatment protocol. “You can’t strictly focus on the cost aspect,” he said.

Limited to 7 Cancer Types
A major change from the OCM is that the new model will cover Medicare patients receiving systemic chemotherapy (meaning those receiving only hormonal therapy are excluded) for 7 cancer types: breast cancer, chronic leukemia, small intestine/colorectal cancer, lung cancer, lymphoma, multiple myeloma, and prostate cancer. This will limit the number of patients covered under the EOM, thus limiting those eligible for MEOS payments. With the MEOS payments themselves trimmed as well, practices will have less money to cover added services, even though practices will likely extend those services to all patients.

The shift has its pluses and minutes, the panelists agreed.

“We can narrow our focus,” Divers said. Benchmarking should be easier for CMMI, “so we can really nail down what the cost of care might be for these tumor types.”

Compared with the OCM, Divers said, the EOM will incorporate more detail about cancer staging and features, so benchmarks and pricing in the EOM should be more accurate. But the question of whether the number of patients covered will be enough to qualify for an Advanced Alternative Payment Model remains to be seen.

“On the plus side, I agree with predictability,” Schleicher said, both from a cost and an accountability standpoint. The question is whether the dramatic cut to MEOS payments and the other shifts in the financial model allow practices to effectively manage high-risk patients, including treatment and palliative care.

Because practices are asked to track social determinants of health (SDOH) and address health equity, not having MEOS payments for all patients is a challenge. “It would have been nice to have everybody still in the model,” Schleicher said, “because quality metrics are going to be important.

"I hope we don’t see a negative impact by not including those [with] early-stage [disease],” Divers added, which could mean fewer touch points and poorer compliance. “It may turn into more advanced disease.”

Making the EOM a “Win”
Staggs asked whether oncologists could combine the EOM with other models within CMMI, such as chronic care management, which could allow them to capture revenue to replace what is being lost in the switch from the OCM to the EOM’s smaller MEOS payments.

Patel sees potential to combine the programs, given that both contribute to reduced per-member per-month spending for Medicare and reduced hospital admissions. “It may help practices to have a little more of a revenue stream to justify a more broad-based approach,” he said.

CMMI had to design a program that was “a win” from a financial perspective, Divers said. “And if you took the MEOS out in OCM, it was a win.”

The challenge is that practices are now asked to do more data collection with less guaranteed revenue and to still meet the new goals of health equity and electronic patient-reported outcomes. Divers noted that CMMI has not offered clear instructions on how to do this; it appears practices can select a vendor of their choosing. Adding this process should be comparatively easy for larger practices, but it is unclear how it will be possible for smaller practices that want to participate.

Schleicher concurred. “We need the data, and we need to learn a lot of these things,” he said, explaining that he is concerned about attracting those practices that have not yet tried value-based care, specifically the OCM. Among the potential roadblocks are the smaller MEOS payments, new reporting requirements, and requirement for 2-sided risk from the start of the model.

“My concern is the selection bias,” Schleicher said; in other words, he fears the model will only attract those practices with prior experience in value-based care, and no new data will be collected from practices that did not try the OCM.

“I’ve already learned how to report in the OCM,” he continued. While new reporting requirements will add important information, they also put new burdens on practices—and that’s a concern for practices that have not yet built a reporting infrastructure.

Addressing Health Equity
Tackling health equity is not a small issue, and “it’s been an issue for a long time,” Staggs said. “What do practices do about that? How do they partner? How do they get started?”

Patel, who has made health equity a centerpiece of his tenure as COA president, said his small oncology practice in South Carolina has set up a program to find resources to improve access for patients who lack financial means for coverage or cost-sharing. The COVID-19 pandemic has increased the need for such measures, he said.

Although improving health equity is a goal of EOM, Patel said, “CMMI has not specified how they’re going to reward practices for addressing that.”
In his own practice, when he set up a program to screen patients for SDOH, he learned that 3 patients were homeless and found them shelter.

But providing such assistance “takes a lot of time and resources,” Patel said, and he is trying now to work with CMMI to create rewards within the model for practices that help patients, “so that [those practices] don’t feel that the model is failing for them.”

Ideally, Divers said, CMMI can aggregate data generated through the EOM that will indicate practices where dollars are best spent to make a difference. Some practices have connections with charitable resources to provide patients with food or with gas cards for transportation, but not all do.

Schleicher said community partnerships can work wonders in this area, but they take time to establish. “These do take infrastructure to build, and then to report on it and learn about—so [it’s] not an easy fix,” he said.

The SDOH focus is an outgrowth of lessons from OCM, Schleicher explained, as practices took responsibility and created structures for keeping patients out of the emergency department (ED) and the hospital.

Smaller MEOS Payments
The panel highlighted how the reduced MEOS payments in the EOM are offset by at least 2 positives: (1) a $30 monthly payment for patients who are eligible for Medicaid, which does not count toward the total cost of care; and (2) the elimination of patient cost-sharing for EOM services, which providers say will encourage advanced care planning.

Schleicher said the list of minuses related to the MEOS changes “is longer,” starting with the fact that reduced revenue comes alongside increased reporting demands. Once again, he emphasized how the combined effect of the financial pieces will drive who signs up for the model. “I worry that we’re going to continue to learn from a selection bias group of practices that have done well and invested in this and are confident enough that they can do well…vs the broader population of cancer care [practices] that would love to rise up and also get involved,” Schleicher said. “What’s the barrier to entry?”

What About Small Practices?
As Staggs pointed out, not every practice has the size and breadth of Schleicher’s Tennessee Oncology or of Texas Oncology, a practice in The US Oncology Network. How does a small practice that wants to pursue the EOM, or value-based care generally, take the first step?

“Don’t try to go it alone,” Schleicher advised. “There are a lot of people to learn from,” including leaders within COA. For his part, Patel said small practices should focus squarely on keeping patients out of the hospital or the ED, not only for cost reasons but also because that is where they can make a significant difference in quality of life.

Practices will definitely need help if they are expected to take on 2-sided risk from the outset, which is another key departure from the OCM. Under the EOM, there are 2 risk levels, with the lower-risk option still requiring practices to report under the Merit-based Incentive Payment System.

Divers said he doesn’t have a problem with asking practices to have some “skin in the game,” and Schleicher agreed to a point—but he worries what will happen if there are problems with the model as it gets up and running, especially for the practices that have no experience from the OCM. Having 2-sided risk “from the start gives me [pause],” he said, adding that practices with no OCM experience should approach the EOM with “a little bit of caution,” he said.

Staggs asked if the EOM option that allows practices to pool data, to compare prior performance periods and savings, offers a solution.

“I don’t know the answer,” Schleicher said. Pooling is being discussed to improve case mix, which in theory could help smaller practices. For large practices that did well under the OCM, there are concerns that performance be measured against prior results, comparisons will still be somewhat against prior results, and it will be hard to continue to find savings. But pooling can also affect an oncology group’s baseline measures, Schleicher said, and so far, there aren’t enough details available for oncology groups to map out whether pooling makes financial sense.

Remove Drug Costs From the Equation
Staggs asked each panelist: If you could change 1 financial element about the EOM, what would it be?

Patel spoke about a trend he’s seeing in his practice. “The biggest unknown is the impact of chronic COVID long-haulers,” he said. “Data are emerging that nationally, 20% of patients will become long-haulers, and this will [mean] more spending, because these patients may be sicker. I have patients who had stable [chronic lymphocytic leukemia], but they now have [atrial fibrillation] because of COVID. [Others] may have thrombophilia…it’s [certainly] going to raise the cost of care.” CMMI must add a risk adjustment that factors long-term effects of COVID into the total cost of care, he said.

For Divers, the reduced MEOS payments are a concern, particularly when it comes to enticing more practices to try a value-based model. “When I think about how you change behavior, economically, you need something to get to get the ball rolling,” he said. “I’m not sure that this MEOS [level] is enough to bring everybody to the table.”

He suggested that CMMI look for creative solutions to tie additional revenue to the back end of performance, based on practices’ data.
Schleicher agreed. Between the rate cut and the population changes, practices will end up with about a quarter of the MEOS payments, “but we still deliver the same care.

“That’s a little tough, especially for groups that haven’t done it yet,” Schleicher said. Complicating matters is that if practices take on more risk under the EOM, newly approved drugs that aren’t yet recognized under the model will, for at least 6 months, be prescribed at an even deeper penalty, with fewer MEOS dollars to offset this cost.

“If there was a way for the appropriate drugs to just not be a part of this, which is easier said than done, then the focus really becomes on the things we can control, like better management of [adverse] effects, better palliative care, better end-of-life care,” and other things that affect patient experience. “It allows you to focus a lot more on those and take out the uncontrollable piece.”

Advances in cancer therapies have offered the greatest improvements in survival, Divers said, but financial models haven’t always kept pace. “You don’t ever want to put a provider—either in your own practice, or in any network—in the position of saying, because of a financial model, ‘I’m being forced from a [economic] perspective, from [the] administration or the government, to…withhold care,’” he said.

“What we ought to understand is that if you have a patient at the center of this model, the most benefit to the patient will come from what you just said: Keep drugs out of the equation,” Patel agreed. This will reduce hospitalization, keep patients out of the ED, help patients get back to work, improve their quality of life, and reduce the cost of care, he said.

“I don’t think any of us would ever withhold care, but it’s still where this [model] is,” Schleicher said. “It takes away the ability to really focus on the things we can control and [to put the] patient first.”

Editor's Note: Watch the episodes of the Stakeholder Summit, “Putting the Enhancing Oncology Model Into Practice” on ajmc.com.