Value-Based Oncology After the Enhancing Oncology Model

Opaque benchmarks, payments that arrive 12 to 18 months after the work is done, and rules that changed mid-model led American Oncology Network (AON) to walk away from the CMS Innovation Center's Enhancing Oncology Model (EOM), according to AON Chief Medical Officer Stephen “Fred” Divers, MD, who spoke with Lalan Wilfong, MD, chief medical officer of Navista, on the inaugural episode of The Business of Value.

AON, a network of practices across roughly 21 states with about 400 providers, operates like a single clinic with 1 electronic health record platform and shared workflows, Divers said. That structure, plus experience in the Oncology Care Model (OCM), made EOM look executable. Still, practices had to accept downside risk and enroll before seeing their benchmarks, and the Inflation Reduction Act changed model performance after enrollment.

Divers framed the payment lag as a behavioral economics problem: when rewards arrive a year or more after the work, it is hard to keep a large network engaged or to convince finance leaders to forgo short-term revenue. Navigation and other unreimbursed services built with the OCM's per-member-per-month payments still operate, he said, but that department now runs at a loss.

Tension was sharpest around 505(b)(2) drugs, which carry separate J-codes and can produce immediate buy-and-bill margin but raise costs in a value-based model where cheaper alternatives exist. AON built separate workflows and relied on pharmacy and therapeutics committees to balance practice finances against model performance without limiting patient access, Divers said, noting carboplatin remains on allocation.

Benchmarking was the biggest frustration. Divers said practices already performing well started with tougher benchmarks, and variables such as trend factors, novel therapy adjusters, radioligand therapies, and a single disease state like myeloma in 1 performance period could swing results. Appeals added months. As participation dwindled and CMS signaled limited resources behind the model, AON exited. Other payers did not follow Medicare's lead, he said, because they were already benefiting from AON's care approach.

AON has since shifted to other value-based arrangements with payers and intermediaries that offer greater clarity, Divers said. Those deals aim to capture outcomes and quality alongside cost, remove pain points such as prior authorization, and rely on real-time data, which he said the EOM never delivered.

"By the time you got your data back,...2 performance periods may have gone by, and you missed all this opportunity to intervene and improve," he said.

Divers said future models should not penalize early adoption of novel therapies, and he advised practices to do their homework but stay willing to pivot.

"You can't be right all the time, but we want to show continuous, steady improvement," he said.

The Business of Value will examine the business decisions behind value-based care in oncology.

Listen above or on one of these podcast services:

Apple Podcasts
TuneIn
Pandora
Spotify