Wednesday, November 30 2022

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Thanks to co-author Danny Costandy, summer associate in Foley’s San Diego office, for his contributions to this post.

The Center for Medicare and Medicaid Innovation (CMMI) is launching a highly anticipated new oncology model, the Enhancing Oncology Model (EOM). EOM succeeds the Oncology Model of Care (OCM), which ended on June 30, 2022 after a five-year demonstration. EOM aligns with Biden-Harris administration goals Cancer Moonshot Initiativewhich aims to improve the cancer experience, drive cancer care transformation, and advance health equity, while reducing Medicare spending.

Similar to the recently completed OCM, EOM is a voluntary model available to all Medicare-enrolled physician groups with at least one oncology physician or advanced practice provider that will run for five years beginning July 1, 2023. ‘EOM encourages participants to take a value-based, patient-centered approach to fee-for-service Medicare beneficiaries receiving routine chemotherapy over time and implement proactive care behaviors. Similar to other CMMI innovation models like Primary Care First (PCF) and Direct Provider Contracting (DPC), the Centers for Medicare & Medicaid Services (CMS) encourages groups of physicians treating underserved populations. served to apply. Additionally, private payers and state Medicaid agencies are encouraged to align with the EOM.

As shown below, EOM requirements build on OCM requirements. Unlike OCM, all MOE participants will be exposed to downside risk. As a result, we anticipate that OCM practices that received performance payouts in the one-sided model or were successful under the two-sided risk model in OCM will apply to participate in EOM.

All qualified physician groups can now apply to participate in EOM through September 30, 2022. As with many other innovation models, approved applicants will choose to participate after receiving a participation agreement from CMS.

EOM and OCM – Similarities and Differences

Similar to OCM, EOM will use six-month episodes of care and requirements for enhanced services, monthly payments, and performance-based payments based on the quality of services provided.

  • The episode-based payout will go from $160 OCM to $70 EOM.
  • EOM participants can choose to charge an enhanced monthly payment of $70 for each beneficiary (and an additional $30 per month for dual-eligibility patients).

EOM participants can choose from two risk agreements that both involve downside risk – a moderate risk profile that should qualify as the Alternative Payment Model (APM) of the Merit-Based Incentive Payment System (MIPS) ) of CMS and a more aggressive risk profile that will qualify as APM MIPS and APM Advanced. Participants can switch between the two risk arrangements between performance years. OCM proposed a unilateral risk agreement qualified as MIPS APM and a bilateral risk agreement qualified as advanced APM.

However, EOM will have fewer eligible beneficiaries than OCM but will have greater potential for cost reduction. The CMO included almost all recipients receiving systemic chemotherapy or hormone therapy for all types of cancer. In contrast, the MOE is limited to beneficiaries receiving systemic chemotherapy for seven types of cancer:

  • breast cancer;
  • chronic leukemia;
  • small intestine/colorectal cancer;
  • lung cancer;
  • lymphoma;
  • multiple myeloma; and
  • Prostate cancer.

Similar to OCM, EOM will require participants to implement the following:

  • Provide 24/7 access to an appropriate clinician with real-time access to patient records;
  • Provide patient navigation;
  • Document a maintenance plan;
  • Use data for quality improvement;
  • Respond to quality measures (eg, patient experience, acute care utilization, symptom and toxicity management, psychosocial health management, palliative care management).

Unlike the OCM, the MOE will additionally require that participants complete a health-related social needs screening; report patient demographics (eg, race, ethnicity, language, gender); develop plans showing how participants will use evidence-based strategies to address health equity gaps in their patient populations; and will slowly implement patient-reported electronic results. For the latter activities, participants’ use of data for quality improvement will be continuously supported by CMS feedback reports that will help the EOM identify disparities within its patient population.

Similar to how OCM participants enjoyed relaxed telehealth and home care under public health emergency waivers, CMS is waiving certain Medicare payment requirements for EOM participants. and expands their patient-centered care management toolkit.

  • Improved telehealth benefits allow a telehealth visit from any location to beneficiaries instead of requiring travel to a health care facility.
  • Enhanced post-discharge benefits allow for up to nine post-discharge home visits by ancillary staff within 90 days of discharge under the general supervision (not direct supervision) of a physician or other practitioner qualified.
  • Enhanced care management home visitation benefits allow for home visits by ancillary staff under the general supervision (not direct supervision) of a physician or other qualified practitioner prior to possible hospitalization.

Former CMO participants, as well as firms that have not participated in the CMO or have joined other innovation models, interested in participating in the EOM should carefully assess whether and how they adapt to successfully participate in the new model.

Foley is here to help you deal with the short and long term impacts as a result of regulatory changes. We have the resources to help you navigate these important legal considerations related to business operations and industry-specific issues. Please contact the authors, your Foley relationship partner, or our healthcare practice group with any questions.

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