On June 27, 2022, the Center for Medicare & Medicaid Innovation (CMMI) announced a new voluntary alternative payment model for physician group practices, the Enhancing Oncology Model (EOM). Interested providers must submit completed applications by September 20, 2022. EOM will commence July 1, 2023, and continue for five years. (UPDATE: This deadline has been extended to Monday, October 10, 2022, by 11:59 p.m. ET.)
EOM is a re-boot of CMMI’s successful Oncology Care Model, which ended June 30, 2022. For each attributed episode (defined as the six-month period during which a traditional Medicare beneficiary receives chemotherapy for breast cancer, chronic leukemia, lung cancer, lymphoma, multiple myeloma, prostate cancer, or small intestine/colorectal cancer), a participating practice will be eligible for a performance-based payment (PBP) based on total episode expenditures and quality performance. The practice also will be liable for a performance-based recoupment (PBR) if such expenditures exceed the assigned episode benchmark by a specified amount.
EOM participants will be required to provide the following enhanced services:
- For each EOM beneficiary, (a) develop a comprehensive care plan, (b) provide patient navigation services with 24/7 access to an appropriate clinician with real-time medical record access, and (c) identify health-related social needs using an appropriate screening tool.
- Treat EOM beneficiaries in a manner consistent with nationally recognized clinical guidelines and utilize data for continuous quality improvement activities.
- Implement electronic Patient-Reported Outcomes.
- Use a Certified EHR Technology (CEHRT) as specified in 42 CFR § 414.1415(a).
To fund these enhancements, EOM participants may elect to receive a $70 Monthly Enhanced Oncology Services (MEOS) payment per beneficiary per month, which will be increased to $100 for dual-eligible beneficiaries. Because the monthly MEOS payments will be included in a beneficiary’s total episode expenditures (excluding the $30 add-on payment for dual-eligible beneficiaries), a participant may forgo these payments to increase its PBPs (or limit its PBRs).
EOM participants also can take advantage of three benefit enhancements associated with waivers of certain Medicare payment requirements: (1) expanded telehealth coverage, (2) post-discharge home visit coverage, and (3) care management home visit coverage.
For EOM, CMMI will use a refined process to calculate benchmarks. CMMI will establish predicted expenditures for each EOM episode using separate price prediction models for each included cancer type and then apply a series of adjustments to obtain the benchmark price for each episode. These adjustments include:
- An experience adjuster to account for regional and participant-specific variation in the cost of oncology care not otherwise accounted for in the price prediction models.
- For certain cancer types, clinical adjusters based on clinical and staging data.
- Cancer type-specific trend factors adjusting for inflation and other cancer type-specific changes in spending patterns occurring across the oncology field as a whole.
- Cancer type-specific novel therapy adjustments to increase the benchmark price for episodes of a given cancer type if an EOM participant has a high share of expenditures within that cancer type for newly FDA-approved oncology drugs.
Unlike OCM, EOM participants will be required to take on downside risk from the beginning of the model, selecting one of two risk arrangements. Under Risk Arrangement 1, the target amount is 96% of the benchmark amount, the downside risk (stop-loss) is 2% of the benchmark amount, and the upside risk (stop-gain) is 4% of the benchmark amount. Under Risk Arrangement 2, these values are set at 97%, 6%, and 12%, respectively.
Under both risk arrangements, the threshold for recoupment is 98% of the benchmark amount, meaning the EOM participant would repay CMS those expenditures above this amount, up to the stop-loss limit. A participant whose total expenditures are greater than its target amount and less than or equal to the threshold for recoupment will neither earn PBP nor owe a PBR. Risk Arrangement 2, which involves a higher degree of risk, is expected to qualify as an Advanced APM under the Quality Payment Program.
CMMI intends EOM to be a multi-payer model and is encouraging commercial payers, Medicare Advantage plans, and state Medicaid agencies to submit payer applications. CMMI will select payers for participation based on application completeness, quality of narratives, and results of program integrity screening. While payers may use different payment incentives, CMMI will require all payers to adopt a consistent approach to oncology practice transformation.
CMMI has posted several resources on its EOM website, including the Request for Application that details all program requirements. Also, CMMI is planning webinars to address the EOM payment methodology and quality reporting requirements in greater detail.
With our knowledge of and experience with oncology practices and CMMI programs, PYA can assist your organization fully evaluate the EOM opportunity and develop an application for the program. For more information, or for additional guidance in these areas or with any matter related to strategy and transactions, compliance, or valuation, one of our executive contacts would be happy to assist. You may email them below, or call (800) 270-9629.
