Mark Liu, MHA
Kelley D. Simpson, MBA
The field of oncology has undergone a significant transformation with the emergence of alternative payment models and a growing emphasis on value-based care. The new Enhancing Oncology Model (EOM) has been dubbed “Version 2.0” of the Oncology Care Model (OCM) and presents the potential to optimize patient care, streamline processes through improved coordination, and reduce the overall costs of cancer.
At the 2023 AONN+ Midyear Conference in Orlando, Kelley D. Simpson, MBA, and Mark Liu, MHA, provided a rundown of what oncology providers can expect from the EOM.
The most notable player in the landscape is Medicare, which has committed to combating the cost of care through drug price negotiation, 340B payment reform, and alternative payment model experimentation.
The Landscape of Alternative Payment Models
In recent years, the development of various alternative payment models in oncology has surged, driven by both payers and providers. The most notable player in the landscape is Medicare, which has committed to combating the cost of care through drug price negotiation, 340B payment reform, and alternative payment model experimentation.
“Medicare, the biggest payer in oncology, is really doubling down on the idea of alternative payment models. That’s important because typically, what Medicare leads with, other payers adopt,” said Ms Simpson, director at Chartis Oncology Solutions and leader at Oncology Solutions Practice in Atlanta. “However, the field of oncology has historically been stubborn to adopt value-based paradigms due to the complexity and heterogeneity of the disease, as well as the cross-specialty nature of oncologists.”
To prepare for this value-based shift, Ms Simpson emphasized the importance of organizations addressing certain oncology value levers that Medicare and commercial payers will look for as part of value-based structures. These include things like enhanced screening/early detection, reduced emergency department visits, and early palliative referral.
“It’s not only about these value levers, but also positioning yourself and evidencing that you deliver quality care, and that you have navigation in place that can lower the overall cost of care,” she added.
Over the years, various models have emerged, each with their own strengths and challenges. The OCM, which ran from 2016 to 2021, aimed to improve patient outcomes while reducing costs. However, it failed to reduce emergency department visits and acute-care spending overall, and it led to substantial financial losses for Medicare during that 5-year period. However, Medicare’s commitment to exploring alternative payment models persisted, resulting in the development of the EOM.
The EOM
The EOM is designed to improve patient care, optimize processes, and reduce costs through a voluntary risk-based approach. The 5-year model is built on episodes of care, each starting with cancer therapy initiation (Part B or D chemotherapy) and a qualifying encounter with a physician. EOM tracks the total cost-of-care expenditures for a specific cancer episode over a 6-month period, including all healthcare claims received by Medicare for a beneficiary after initiation of cancer therapy, and extending beyond cancer-related expenses (eg, a necessary hip replacement). Beneficiaries enrolled in clinical trials can also participate in the model. However, patients receiving CAR T-cell therapy are excluded from participation, as these treatments are incredibly expensive and represent extreme outliers in terms of overall cost.
Unlike its predecessor, EOM narrows its focus to 7 high-volume cancer types: breast (low-risk breast excluded), chronic leukemia, lung, lymphoma, multiple myeloma, prostate (low-intensity prostate excluded), and small intestine/colorectal cancer.
“The OCM tried to boil the ocean in terms of including all cancers under the sun, but they learned from that,” noted Mr Liu, senior director of Oncology Strategy, Transformation & Analytics at Mount Sinai Health System in New York, NY.
By creating 7 different models tailored to each of these cancer types, EOM aims to offer a more accurate representation of patient populations. To support providers in this endeavor, the model introduced $70/month/beneficiary Monthly Enhanced Oncology Service payments (reduced from $160/month with OCM). These payments count toward the total cost of care and offer upfront funding that allows practices to improve care by investing in navigation and other value-driven services.
EOM participants will either earn a performance-based payment (if total expenditures for attributed episodes are below a risk-adjusted target amount), will owe a performance-based recoupment (if total expenditures for attributed episodes exceed the threshold for recoupment), or they will fall into a “neutral zone,” neither earning nor owing. Mr Liu noted that there are benefits to participation regardless of where participants fall after the 6-month performance period, including quarterly feedback reports, semiannual reconciliation reports, and monthly claims data from the Centers for Medicare & Medicaid Services.
Navigation Considerations With the EOM
“The goals of patient navigation are directly aligned with value-based care in cancer,” said Mr Liu.
EOM participants will be required to provide the core functions of patient navigation, as appropriate, to all EOM beneficiaries who request and/or need these services. Navigators play a pivotal role in the success of the EOM by facilitating coordination, communication, education, and support for patients, as well as ensuring timely and seamless care delivery.
New for EOM is required screening for health-related social needs. By using screening tools like the National Comprehensive Cancer Network Distress Thermometer, navigators can assess factors such as patient food security, and transportation and housing needs. Addressing these social determinants of health can significantly impact patient outcomes and cost of care.
Another new component of EOM is gradual implementation of electronic patient-reported outcome tracking, in which navigators play a vital role. By implementing tools that allow patients to report on their outcomes and experiences, patient engagement and empowerment is increased, the patient/provider partnership is enhanced, and overall quality of care is improved.
The EOM represents a pivotal step in the shift toward value-based care in oncology, and as the healthcare landscape continues to evolve, the ability of navigators to bridge gaps, address social determinants of health, and foster collaboration between patients, caregivers, and providers positions them as indispensable members of the care team.
“Navigators are superheroes,” said Ms Simpson. “I truly believe you have the power to reduce the cost of care, to streamline services, to meet timeliness-of-care paradigms, to connect patients with all the meaningful resources that they need, and to allow them to have the best consumer experience possible.”
