Back in July, I offered a Enhanced Oncology Model (EOM) Overview. Today I build on that post and focus on CMS Payment method for EOM. I also use a question and answer format.
What is the goal of EOM?
According to CMS, “EOM is a CMMI alternative payment model designed to advance health equity, facilitate better coordination of care, improve access to care, reduce costs, and improve fee-for-service (FFS) for cancer Medicare receiving chemotherapy. beneficiary outcome.”
Which cancer types are eligible for EOM?
Seven cancer types are eligible for EOM: (i) breast cancer, (ii) chronic leukemia, (iii) lung cancer, (iv) lymphoma, (v) multiple myeloma, (vi) prostate cancer, and (vii) ) Small bowel/colorectal cancer.
Note that low-risk breast cancer (ie, long-term oral endocrine chemotherapy) and low-intensity prostate cancer (indicated by androgen deprivation and/or antiandrogen therapy without chemotherapy) are not included in the EOM.
Does EOM only consider chemotherapy?
Do not! Although the term “chemotherapy” is frequently used in all CMS languages, EOM initial treatment includes not only traditional chemotherapy (eg, azacitidine, carboplatin, decitabine), but also immuno-oncology therapies (eg, nivolumab , pembrolizumab) and targeted therapies (eg, bevacizumab, osimertinib, sorafenib? A full list is available on the EOM website here.
Cell and gene therapies—what CMS calls adoptive cell transfer (ACT) therapy—are excluded from the EOM program. For example, CAR T-cell therapy is excluded from the EOM program.
How long are EOM episodes?
6 months.
The episode begins with a “trigger event,” which is initiation of a Part B or D cancer drug. Beneficiaries who continued chemotherapy after completing six months of treatment started a new treatment. Note, however, that “there is no requirement that there be a chemotherapy-free period prior to the onset of any episode.” To account for the lack of a “cleaning period” prior to triggering events, CMS relies on risk adjustment.
How are episodes allocated to physician practice groups?
This is based on the practice of the Oncologist Panel to (i) provide first evaluation and management (E&M) services within a 6-month executive period as long as they provide at least 25% of the E&M services in the episode, or (ii) If the initial PGP does not meet the 25% threshold, the PGP has multiple E&M services.
What types of payments are available for Physician Group Practice (PGP)?
The clinic accepts standard Medicare FFS billing. In addition, EOM has the option to include monthly Enhanced Oncology Services (MEOS) payments, which can be considered a capitation payment. The base MEOS payment is $70 per month, but increases to $100 per month for dual eligible beneficiaries. Based on treatment cost and quality, PGPs have two-sided risks: high-quality/low-cost PGPs can receive retrospective performance-based payment (PBP), but low-quality/high-cost PGPs may owe retrospective performance-based compensation (PBR).
PBP and PBR depend on the chosen risk model. By default, EOM participants and pools are in RA1 unless they request to be in RA2. The payment specifications for RA1 and RA2 are as follows. RA1 requires PGP to hit a larger target discount (4%), but with a maximum downside risk of 2%; RA2 requires a smaller discount (3%), but PGP needs to take more positive and negative risks (maximum 6% risk). By default, EOM participants and pools are in RA1 unless they request to be in RA2.
What type of spending is included in an episode?
All Medicare Part A and Part B FFS payments (payments) and certain Part D payments count as part of the episode cost. Specifically, EOM events only included Low Income Cost Sharing Subsidy (LICS) amounts and 80% of total drug costs above the catastrophic (GDCA) threshold. All other Part D expenditures are not included in the EOM plot because they are paid per capita by the Part D program.
How does EOM account for differences in unusual events and patient characteristics?
To reduce the likelihood that some very high or very low cost episodes would result in poor performance scores, CMS shrinks episode spend at the 5th and 95th percentiles.
In addition, CMS risk was assessed according to demographics (i.e., age, sex), income (i.e., dual eligibility, Part D LIS eligibility), comorbidities (autoimmune disease, COPD, dementia, endocrine disorders, heart disease, blood disease, etc.) Factors) adjusting for episode cost, hypertension), count of other HCC, receipt of specific services (ie, cancer-specific surgery, bone marrow transplant, radiotherapy), institutional status, participation in clinical trials, prior chemotherapy use, and duration of episodes (e.g. in case of death or withdrawal)
obesity. The risk-adjusted 50% was based on a mix of country-specific cancer cost projections and regional and PGP-specific cost estimates, with larger PGPs weighting historical data more and smaller PGPs weighting regional cost projections more.
See below for more details on how CMS calculates the PGP target amount for EOM participants.
Does EOM take tumor stage or tumor mutation into account?
Yes, but rough. There is a clinical adjuster if the patient has had metastatic disease (currently only for breast, lung, and small bowel/colorectal cancer), and it is adjusted for a single biomarker (HER2+ breast cancer patients).
How is EOM responding to new treatments?
EOM may inhibit the use of clinically beneficial but costly treatments. In order not to unduly stifle innovation, the EOM includes a new treatment adjustment whereby oncology drugs are considered “new” within 2 years of FDA approval for that particular indication.
Does the EOM take quality of care into account?
some. EOM does this through an aggregate quality score (AQS). In short, PGPs are only eligible for bonuses if they meet the AQS minimum threshold.
Quality of care includes certain activities (24/7 access to care, patient navigation, documented care plan, adherence to clinical guidelines, screening for health-related social needs, and use of certified electronic health record technology (CEHRT). Specific quality Measures are listed below based on CMS’s Quality Strategy Webinar From 25 August 2022.
For more details on EOM evolution, see CMS’s EOM website.
