Value-Based Care Veterans, Surprised by EOM Results, Ponder Next Move

Few leaders in community oncology have rallied for value-based care more than Sibel Blau, MD, who serves as president and executive chair of Northwest Medical Specialties, PLLC, in Washington State and is co-founder and president and CEO of the ONCare Alliance LLC.

Sibel Blau, MD | Image: LinkedIn

Lalan Wilfong, MD | Image: LinkedIn

For years, Blau traveled from the Pacific Northwest to join colleagues in discussions on how to master the Oncology Care Model (OCM), which ran from 2016 to 2022, and later the Enhancing Oncology Model (EOM). When the EOM focused on health-related social needs, Blau’s practice was among the first to go through CMS’ process for implementing a health equity access plan.

As Blau shared during a panel discussion Tuesday during the Community Oncology Alliance (COA) Payer Exchange Summit, practice transformation has been hard work. But it was the right thing to do, and those who put in the effort were rewarded.

But differences between the OCM and EOM—and changing dynamics in the drug market—may mean CMS’ signature payment model in oncology is no longer a good deal, even for those most committed to the cause.

The most recent EOM performance results—for a time period that covered January 1 to June 30, 2024—show that Blau will not get a performance bonus for the first time ever, going back to the OCM days. As results circulated ahead of the summit, moderator Lalan Wilfong, MD, senior vice president of Value-Based Care for Thyme Care, surveyed practices and found similar surprises—along with equal levels of frustration as to why.

“It’s a big change,” Blau said. “This is the first time in the entire history that we’ve been doing this… And now, where does it put me? I want to do this, I want to learn, I want to adapt, but we've already done other great things, and I'm doubting this whole decision.”

Kate Baker, MD, MMHC | Image: Tennessee Oncology

Puneeth Indurial, MD, MS | Image: AON

Richard Ingram, MD | Image: Shenandoah Oncology

Other panelists shared Blau’s concerns and said their practices are weighing what to do next. They were Kate Baker, MD, MMHC,medical director, Value-Based Care, Tennessee Oncology; Puneeth Indurial, MD, MS, senior vice president, Strategic Operations, American Oncology Network, and Richard Ingram, MD, FASCO, of Shenandoah Oncology, PC.

All said their practices had made significant investments in value-based care and wanted to stay the course with the EOM. For years, there have been rumblings that a Medicare value-based model might be mandatory, so practices wanted to be ready.

“We wanted to see if we could maybe stay ahead of the curve, as a small practice,” Ingram said.

From OCM to EOM—Small Numbers, Big Differences

The OCM was considered a success in promoting practice transformation, but it cost Medicare $315 million. When the Biden administration replaced OCM with the EOM, the new model was designed to cost less and to force practices to operate under narrow parameters and at risk from day 1. This has proved challenging. Wilfong said an earlier COA session with CMS leadership addressed the challenge of designing a program that could simultaneously capture needs of both large, multisite practices and small ones.

As Wilfong explained, practices in the EOM are evaluated on how well they manage cancer episodes compared with other practices within that same type of cancer, not against all cancer types; thus, a single expensive case can wreak havoc on performance, especially in small practices. In addition, the OCM covered most cancer types; the EOM includes only 7 common cancers.

Earlier this year, multiple practices reported that they had positive results and received a performance bonus for Performance Period 1 (PP1), which ran from July 1, 2023, to December 31, 2023. But as results went out for Performance Period 2 (PP2) which ran January 1, 2024, through June 30, 2024, many of the same practices did not get bonuses, or those eligible for bonuses are seeing much smaller payments, Wilfong said. Practices that fall short of benchmarks may owe the government money.

This was the buzz of the COA Summit, because no one—not even the CMS representative who spoke privately with practice leaders—could fully explain the results.

“It’s such a stark difference between PP1 and PP2 in terms of our performance as well, and without us really changing anything operationally or culturally or anything like that,” Baker said. “We’re really just trying to dig into our data now and see if we can see big differences.”

Wilfong and fellow panelists pondered whether individual drug pricing changes could have triggered some disruptions. Possibilities include shifts in a popular therapeutic for pancreatic cancer that occurred during the time frame, as well as adoption of 4-drug regimens in newly diagnosed multiple myeloma, following presentation of the PERSEUS trial at the American Society of Hematology in December 2023. FDA approved the regimen in July 2024.

In addition, Wilfong explained how many practices were able to achieve significant cost-of-care savings in the OCM through the use of biosimilars. Today, however, that market is now disrupted by more expensive biosimilars and the rise of 505(b)(2) drugs, which are noninterchangeable competitors that are approved via a different pathway.

Today, Blau said, “It’s very unstable.”

Data Lag Is a Huge Problem

Going back to the OCM days, the lag between when care occurs and when practices learn their results is an ongoing challenge. How can practices learn if 2 more performance periods elapse before they get data?

As Indurial said, the EOM is "a nicely designed map without a compass." Oncologists and practice administrators don’t know in real time what is happening nationwide with drug pricing, or how this will drive trend factor calculations. All this feeds into the results that affect how the practices compare with others. But in the moment, treatment decisions are based on what is best for the patient, as well as factors such as what payers will cover or possibly whether a certain drug is in shortage.

As opportunities for performance-based payments shrink or become less reliable, the EOM’s administrative requirements loom larger, the panelists said. Among commercial payers, Indurial said, “You see a lot of different flavors of the same program, or completely different programs coming up to commercial payers and Medicare Advantage plans, and now you're left with the administrative burden of having to navigate each one of them individually.”

Despite efforts to automate reporting elements, Ingram said, “You can't understate the manual nature,” of the data extraction process.

As with any program, efforts to make things easier can fall short. Baker said the Center for Medicare and Medicaid Innovation has tried to reduce burdens by aligning the Merit-based Incentive Payment System (MIPS) requirements with EOM, but some self-selection measures don’t like up with other reporting requirements beyond MIPS.

From the start, EOM had fewer practices than OCM, which opened with more than 200 practices and had 122 when it closed June 30, 2022. EOM opened with 44 practices and lists 38 on its website. Wilfong asked the panelists whether their practices or networks will go forward with EOM; they must decide by November 30. (AON includes many small practices that enroll as a single tax ID number). The collective answer seemed to be “to be determined,” although Ingram said his practice would stay for now.

Indurial said his team would scrutinize the model closely. “We’ll definitely undertake a deeper look at whether participation makes sense on an ongoing basis," he said. "Because at the end of the day, we have to keep the doors open. Otherwise, patients don’t get care.”