New Enhancing Oncology Model Builds on Knowledge From the OCM

Evidence-Based Oncology, August 2022, Volume 28, Issue 6
Pages: SP405

SAP Partners | <b>US Oncology Network</b>

When the Center for Medicare & Medicaid Innovation (CMMI) announced the Oncology Care Model (OCM) in 2015,1 The US Oncology Network (The Network) was excited to see an oncology-specific model that focused on all aspects of value-based care. Aimed at improving the patient experience and quality outcomes while also bending the cost curve, the OCM pilot program completed a 6-year run, and its replacement, a new program called the Enhancing Oncology Model (EOM), has just been announced.2 Performance Period (PP) 9 results for the OCM have been reported, and The Network practices earned top quality metrics while delivering substantial cost savings. Steady progress resulted in significant achievements. A closer look at The Network PP9 results and how they were achieved, as well as an overview of the new EOM program, may provide some valuable insight to help practices and payers successfully transition to the new model.

Patient Care Improved, and Savings Were Seen
The Network eagerly embraced the OCM, viewing it as a way to reduce costs while improving the quality of care, the patient experience, and patient outcomes. Since OCM’s start in July 2016 through May 2022, the 14 practices in The Network participating in the OCM enrolled more than 125,000 unique patients into the program.

The OCM was structured as an episode-based payment model, with each episode triggered when a patient received a qualifying chemotherapy treatment. Starting on July 1, 2016, practices were evaluated for each 6-month interval of participation, known as a Performance Period. Practices were evaluated based on total care provided for the patient, including nononcology care.3

Program metrics across The Network steadily improved over time, culminating in impressive results for PP9. Of note:

All 14 participating practices achieved a 100% performance multiplier for the last 2 Performance Periods, demonstrating a continued improvement in quality even during the challenges brought about by COVID-19 that began in 2020. (The performance multiplier is a calculation based on a practice’s quality scores.)

Comparing late 2020 with late 2016, The Network saw (1) emergency department (ED) visits reduced by 24% across the 14 participating practices; (2) hospice utilization beginning more than 3 days before death increased by 11%; and (3) hospitalizations, a performance measure eliminated by CMS but still tracked by The Network, fell by 37%.

  • Patient-focused quality measures improved for pain, depression, and patient experience from measure inception through PP9. Thirteen of the 14 practices achieved 10 of 10 points for pain, while nine practices earned 10 of 10 points for depression. Steady improvement was also noted for patient experience from PP3, when the measure was first introduced, through PP9.
  • Within The Network, 86% of OCM practices beat their benchmark amount for total cost, compared with 75% for all OCM practices nationwide.
  • Over the first 4.5 years of the OCM—through PP9—practices in The Network saved Medicare $240 million compared with the benchmark amount. These high-performing organizations received some of those dollars back in shared savings.

Resources to Drive and Support Success
For oncology practices, the OCM was a journey into unknown territory: It required a whole new way of doing business, as practices had to transition from volume-based reimbursement models to a new model focused on delivering more value. Given its periodic rule changes, frequent updates, and complex reporting requirements, it was challenging for practices to try to implement this complex program on their own. However, comprehensive, proven resources provided by The Network and McKesson were utilized by all OCM practices across The Network. These included industry-leading technologies to support decision-making at the point of care, advanced analytics to provide actionable data and optimal data management, innovative pharmacy solutions to drive and support efficient drug management, and many other useful resources. Practices also had access to thought leaders and key staff with deep expertise in value-based care.

Each of the 14 practices participating in the OCM was assigned a Network Value-Based Care Transformation Lead, an expert to guide the practice not only on program requirements, but also performance improvement. The Transformation Team was formed to develop and utilize many innovative tools and consistent activities to drive deep model adoption and improve OCM outcomes. Toolkits for pain, depression, ED and hospital utilization, hierarchical condition category documentation, geriatric risk, and advance care planning were developed in collaboration with practices’ Quality Leadership to guide practices in these critical areas. Regular meetings were held for several reasons: to keep practices informed about program changes, to ensure they were making progress on key action plans, to coach them through any difficulties, and especially to share success stories. Practice workshops were also conducted to focus on solutions to reduce costs and improve care. All of these components worked together, creating a synergy that drove success in this complex program.

Pivoting to the Enhanced Oncology Model
The Network is encouraged by what is known so far about the new program, as its foundation is the assemblage of OCM’s many successes. Six practice-redesign activities in the OCM are carrying forward to the EOM, building on what practices have already done around shared decision-making, care and treatment plans, advance care planning, navigation, survivorship, and enhanced services.

Two new redesign activities have been added to the requirements. Practices must now have technology in place for electronic Patient Reported Outcomes (ePROs) by year 3 to proactively receive reported outcomes from patients. The second additional redesign activity addresses health-related social needs, requiring practices to assess patients to identify those at risk in areas like transportation, housing, and food insecurity.

Although CMMI has not defined the quality measures yet, it is likely there will be substantial carryover in quality improvement based on the go forward themes; a deeper focus on health equity is likely as well. Much like the OCM, the model will aim to reduce the need for care at higher acuity levels, such as ED visits and hospitalization.

A big difference between the OCM and the new model is that the EOM will enroll only those patients who are receiving systemic chemotherapy for 1 of 7 prevalent, high-risk cancers: multiple myeloma, chronic leukemia, lymphoma, small intestine/colorectal cancer, and breast, lung, and prostate cancers. Patients receiving only hormonal therapy, such as those with low-risk breast and prostate cancer, are excluded. Model outcomes are focused around the needs of patients who have a higher risk because of the complexity of their diagnoses and cancer therapies. This allows practices to focus on the patients who have heightened needs, but the enhanced services funding will be lower in accordance with the smaller patient population.4

Overall, the program is a good progression from the OCM, carrying over benefits on the quality and redesign fronts, and building on activities The Network has already started to support and expand around equity and social determinants of health. EOM is voluntary, more patient-centric than the last model, and has an even greater focus on patient health equity, while it also expands into broader areas of practice redesign such as ePROs.

A Closer Look at the Challenges
Practices in the OCM had the opportunity to remain in 1-sided risk the first few years to see whether they received a performance-based payment. That is not the case with the EOM: Practices are immediately jumping into 2-sided risk, increasing financial risk prior to fully understanding how to succeed.

On the positive side, CMMI is providing 2 different 2-sided risk plans: lower-risk and higher-risk models. In the higher-risk program, practices have more earning potential, but in turn they face higher penalties if they fail to achieve quality and savings benchmarks. There is a bit more fairness with the EOM around quality performance and payback, compared with the OCM, because CMMI will apply the quality score to the practice’s downside payback if one is due, reducing the amount owed to CMS in return for delivering measurable high quality care.

The upfront payment received under the EOM to fund enhanced services will be reduced from the OCM’s $160 a month, down to $70 a month for Medicare patients and to $100 a month for patients dually eligible for Medicare and Medicaid.

Practices must carefully examine their options when considering participation. We will work with Network practices to analyze care management funding in tandem with the risks they could face to determine the upside vs potential downside of having to perform at 98% of benchmark to be neutral or better.

Payers can participate. Payers are being encouraged to partner with the EOM program through a multipayer model geared for private payers, Medicare Advantage plans, and Medicaid agencies at the state level. To participate, payers must be closely aligned with the tenets of the model, especially around equity, data sharing, and payments. They must also partner with an EOM participant for the duration of the model, so practice engagement is required.

Lessons Learned for Payers and Practices
The OCM offered 2 important lessons that can help managed care executives make good decisions as they transition to the EOM. First, from a managed care standpoint, the more value-based programs are aligned across the oncology landscape, the easier it is for practices to implement a program and make the necessary changes required for patient, program, and practice success. Consequently, payers should strive to find ways to achieve more similarities across models. The EOM is a good opportunity for payers to create more harmonization by getting all programs more aligned, creating strong momentum to drive the overall transformation of oncology to value-based care.

Second, in some of the commercial arenas, such as managed care, models tend to change fairly often. Payers frequently try a program for a year and then switch to something else, rather than leaving it in place long enough for results to take hold. This quick turnaround inhibits the ability to analyze what is working and what is not, depriving practices of vital information they needed to improve a program.

From a practice perspective, for those trying to partner with payers, it is imperative to know where your practice stands from a quality and cost standpoint. Practices need to address key issues, such as where improvement is needed, how the practice can partner with payers around areas of change, and how to keep patients at the center of initiatives while ensuring that they receive all needed services. The payer/practice partnership is critical, as the payer and the practice together enable value-based care.

Careful Evaluation Is the First Step to the EOM
With value-based care, practices have to perform a balancing act, trying to provide high-quality, cost-efficient care, optimal patient experiences, and sustainable outcomes while also taking on a tolerable amount of risk. Only time will tell whether the EOM can deliver all of these critical elements.
The Network will be helping its practices determine the viability of the EOM for their organizations, doing a deep dive and collaborating with each practice to determine the benefits and risks of jumping into this new model.

Our initial go-forward approach will be to encourage all practices to consider applying by September 30, 2022, then continue to evaluate the model as they make the decision whether to sign the agreement, which could happen this winter or spring. 

Our initial go-forward approach will be to encourage all practices to consider applying by September 30, 2022, then continue to evaluate the model as they make the decision whether to sign the agreement, which could happen this winter or spring. 


Author Information

Stuart Staggs, MSIE, is senior director of strategic programs for The US Oncology Network.

CMMI Disclaimer
The statements contained in this document are solely those of the author and do not necessarily reflect the views or policies of CMS. The author assumes responsibility for the accuracy and completeness of the information contained in this document.

References
1. Oncology Care Model. CMS. Updated July 20, 2022. Accessed July 16, 2022. https://innovation.cms.gov/innovation-models/oncology-care
2. Enhancing Oncology Model. CMS. Updated July 19, 2022. Accessed July 16, 2022. https://innovation.cms.gov/innovation-models/enhancing-oncology-model
3. Carey BP. Healthcare alert: Oncology Care Model. Foley Hoag LLP. July 1, 2016. Accessed July 16, 2022. https://foleyhoag.com/publications/alerts-and-updates/2016/june/oncology-care-model
4. Fact sheet: Enhancing Oncology Model. CMS. June 27, 2022. Accessed July 16, 2022. https://www.cms.gov/newsroom/fact-sheets/enhancing-oncology-model