CMS Unveils Replacement for the Oncology Care Model

The Centers for Medicare & Medicaid Services (CMS) has announced a new, voluntary alternative payment model, which will replace the Oncology Care Model (OCM) that ended on June 30.

The OCM's successor, known as the Enhancing Oncology Model (EOM), will begin next year on July 1, and run for 5 years.

Like the OCM, the EOM will align payment incentives with care quality, and focus on value-based, patient-centered care for those undergoing chemotherapy based on 6-month episodes of care. The EOM will focus on health equity, and participants will include oncology practices that treat Medicare beneficiaries receiving chemotherapy for seven types of cancer: breast cancer, chronic leukemia, lung cancer, lymphoma, multiple myeloma, prostate cancer, and small intestine/colorectal cancer.

The new model will build on lessons learned from the OCM, incorporating successful elements of the previous model, such as patient navigation and care planning, and will introduce new elements, including gradually implementing electronic Patient-Reported Outcomes and activities that promote health equity.

In a statement, CMS Administrator Chiquita Brooks-LaSure noted that the EOM 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."

The goal, Brooks-LaSure added, is to address "stark inequities in the ability of people with cancer across race, gender, region, and income to access cancer screening, diagnostics, and treatment. CMS is working to advance President Biden’s Cancer Moonshot goals by helping Medicare cancer patients better navigate a challenging and often overwhelming journey."

Applauds and Concerns

The American Society of Clinical Oncology (ASCO), the Association of Community Cancer Centers (ACCC), and the Community Oncology Alliance (COA) all issued statements applauding the new model and the fact that it is voluntary. But they have also voiced several concerns.

The COA, for example, noted that the CMS Innovation Center plans to cut the Monthly Enhanced Oncology Services payments in the EOM by more than half ($70 vs $160 for the OCM), but at the same time, expects more work from practices.

While COA is "extremely supportive" of screening for health-related social needs and electronic patient-reported outcomes, "it seems unfair to burden practices with more work but pay less for it, particularly as practices are dealing with the return of the Medicare sequester cut, inflation, and ongoing COVID-19 practice challenges," Ted Okon, executive director of COA, wrote in a statement.

COA also expressed concern with the 1-year gap between the end of the OCM and the start of EOM.

"During this time practices will have to shoulder the extensive investments and operational changes put in place to benefit patients without reimbursement," Okon said.

ASCO echoed COA's concerns and the ACCC expressed unease with some of the structural elements of the program.

The EOM includes two risk arrangements with different degrees of downside risk. However, requiring participants to accept downside risk from the start of the model "will be a significant barrier to enrollment given the current reimbursement landscape," the ACCC said in a statement. This risk "may not make financial sense for smaller oncology programs, particularly those who care for underserved patients and those that have not previously participated in OCM."

Instead, CMS should "endeavor to provide as much information on proposed payment methodologies, cost data, and benchmark amounts as early as possible so that practices can make informed decisions around participation," the ACCC wrote.

An Improvement Over OCM?

The OCM represented the largest alternative payment model to address value-based payment for cancer care. More than 3200 oncologists and 201 physician practices voluntarily entered the program, which lasted 6 years.

But since its implementation, studies assessing the success of the program have yielded mixed results.

A 2018 analysis, for instance, revealed that one large community practice saved Medicare $3 million over a year after adopting the OCM.

However, a 2021 study found that while community practices experienced lower drug costs in lung and prostate cancer and lower office-based costs after implementing the program, the difference was not statistically significant when accounting for all costs.

Another analysis also revealed more mixed results, reporting cost reductions for all cancers, but also finding those savings were offset by administrative expenses. Overall, this study found the OCM led to a $155 million net loss to Medicare over 4 years.

Will the EOM Improve Upon the OCM?

According to the CMS, "the central goal of EOM is to better support patients and improve their care experience."

Participating Physician Group Practices will take accountability for healthcare quality and total spending during 6-month episodes of care for Medicare patients with certain cancers.

CMS will give participants the option to bill for Monthly Enhanced Oncology Services payment for services provided to eligible beneficiaries. This payment will be higher for beneficiaries dually eligible for Medicare and Medicaid.

EOM participants will have the opportunity to earn a retrospective performance-based payment based on quality and savings. Participants will be required to take on downside risk from the start of the model, with the potential to owe CMS a performance-based recoupment.

EOM participants will be required to implement participant redesign activities, including 24/7 access to care, patient navigation, care planning, use of evidence-based guidelines, use of electronic Patient Reported Outcomes, screening for health-related social needs, use of data for quality improvement, and use of certified electronic health record technology.

"No one should have to battle cancer without access to high-quality, coordinated care," said HHS Secretary Xavier Becerra, in a statement. "With this new Innovation Center model for oncology care, we are delivering on President Biden’s call to action to mobilize every option to address cancer, and creating a system of care that supports all patients and their families."

A detailed payment methodology paper will be published for EOM this summer and will be available on the Innovation Center’s website.

Roxanne Nelson is a registered nurse and an award-winning medical writer who has written for many major news outlets and is a regular contributor to Medscape.

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