A chief concern among those considering the upcoming alternative payment model in oncology, the Enhancing Oncology Model (EOM): Practices will have to take on downside risk immediately.
To open Thursday’s discussion on payment reform at the Community Oncology Alliance (COA) 2023 Community Oncology Conference, moderator Judith Alberto, MHA, RPh, BCOP, COA’s director of Clinical Initiatives, asked several times for a show of hands.
How many in the room had taken part in the Oncology Care Model (OCM)?
Hands went up around the room.
How many had applied to take part in the Enhancing Oncology Model (EOM)?
A few more hands joined them.
Finally, how many were planning to join the EOM if they received a participation agreement from the Center for Medicare and Medicaid Innovation (CMMI)?
Hands fell everywhere.
That summed up the sentiment about the EOM among oncologists and practice administrators attending this week’s COA meeting. When the EOM was presented in late June 2022, many practices had hoped by this point they would be saying "yes" to the model. This was especially true among those who spent years fine-tuning their performance in the OCM, which for 6 years was Medicare’s chief way for oncologists take part in an alternative payment model under the 2015 Medicare Access and CHIP Reauthorization Act.
But as the July 1, 2023, EOM implementation date nears, questions remain, and Alberto and her fellow panelists explored many of them. Joining her were T.R. Strickland, a value-based care consultant; Anne Marie Rainey, MSN, RN, CHC, director of quality and value-based care for Clearview Cancer Institute, based in Anniston, Alabama; and Matthew R. Skelton, MD, an oncologist with Blue Ridge Cancer Care, based in Roanoke, Virginia.
Rainey and other at the COA meeting say participation agreements that were anticipated weeks ago from CMMI have yet to materialize, making it hard for practices to know what they are agreeing to do if they want to proceed.
Those on hand have many concerns, but chief among them is the EOM requirement to take on downside risk form the outset—something that the OCM did not do. And yet, as the panelists explained, not joining the EOM carries its own risk, as many believe that CMS will someday make risk-based reimbursement mandatory; thus, time spent in the EOM will be a worthwhile investment.
The cultural change achieved over 6 years in the OCM was hard won, and no practice wants to backslide, the panelists agreed. A major consideration for taking part in the EOM, Skelton said, is “If youdon’t do it, you’re going to be left behind.”
Retaining the patient-centered approach that the OCM promoted is key, Rainey said. “If we focus more on the patient and keeping the patient in the center, and doing what's right from the start, then that puts us on the best trajectory to solve some of the problems that we have,” she said.
EOM Alongside Other Concerns
Deciding whether to join the EOM would be monumental enough if it was the only major action coming from CMS, but it’s not. As Strickland noted, practices are also figuring out the near-term impact of the Inflation Reduction Act, as most practices still have most of their revenue tied to fee-for-service (FFS) models.
CMS and health plans are also aggressively marketing Medicare Advantage (MA) plans to retirees, and oncologists continue to report issues with “fail first” requirements in these plans that prevent them from giving patients the best therapy available.
And the panelists expressed frustration that the OCM ended just as practices had finally mastered its nuances. Skelton cited figures from The US Oncology Network, of which Blue Ridge is a part, that showed these practices saved Medicare more than $300 million, of which the practices retained a third.
“And on top of that, patients are doing better. That should be first and foremost,” Skelton said. Data show that patients spent less time in the hospital and pursued hospice earlier. “That turned some skeptics around,” he said.
Practices have many concerns about the EOM, Rainey said. Although critics say the model essentially asks practices to do more and be paid less, Rainey was less harsh. But she did outline some of the challenges:
Above all, however, the panelists had doubts that the requirement to take on downside risk was responsible or fair to practices that had no experience with value-based care, if, in fact, CMS plans to someday make this type of payment system mandatory.
Alberto asked the panelists what they might change about the EOM as currently designed. Rainey was very specific: Give practices the first performance period without downside risk.
“This is a chance to get some data see how it performs,” she said.
Although former OCM practices have some knowledge, they will have far fewer patients in the model—due to the EOM’s limit to 7 cancer types.
“We just don’t know exactly what that’s going to look like with a smaller patient population,” she added.
At this stage, Rainey said, CMMI may want to reconsider the timeline for the EOM.
For example, Rainey’s own practice is “very on the fence” about the EOM because it has acquired 3 locations that were not part of the OCM. Giving those locations an initial period to collect data before taking on risk would increase the practice’s comfort.
Skelton agreed. “Two-sided risk right out of the gate is a disincentive,” he said, if the goal of CMMI is “a solution for the country and not just super high-performing practices.” He noted that even the most successful OCM practices took 3 to 4 performance periods—which were 6 months each—to learn to work the model.
Strickland noted that after the early performance periods, CMMI changed methodology based on feedback, and then practices were finally able to see their data—and performance improved. “Value-based care is usually built in a progressive manner,” he said.
Both Strickland and Rainey said practices are considering tapping into the chronic care management model, which could replace revenue being lost due to reduced monthly payments under the EOM.
To conclude the session, Alberto asked the panelists what is preventing the health system from putting oncology care where it wants to be?
Rainey said technology to help with decision-making is still not optimal, and Strickland agreed that more must be done to make collaboration seamless.
Skelton said physicians feel “resentment” when third-party payers dictate what therapies they can use, and so much time is wasted doing battle to work through prior authorization just to give patients guideline-directed care. As frustrating as it is, he said, physicians must advocate for their patients, because “Who else is going to do it?"