by Dr. Jeffrey A. Scott, Chief Medical Officer.
In our previous blog post, we broke down CMS’ assessment of the Oncology Care Model (OCM) and found that there were both positive and negative components to the five-year value-based care program, which ended in June of 2022.
Now, as oncology practices send in their applications for the new Enhancing Oncology Model (EOM) that’s slated to begin in July of 2023, we want to take a deeper dive into how some practices succeeded in OCM – and how they and their colleagues can continue to perform well throughout the next iteration of value-based care for oncology providers.
What made some oncology practices more successful in OCM than others?
The most successful practices were able to reduce acute care admissions, enhance patient access and thereby avoid unnecessary ED visits, make more cost-effective drug choices, including the use of biosimilars, and reduce unnecessary chemotherapy and hospitalizations at the end of life. Value-based care is about more than just controlling costs. It is, at its core, about improving patient outcomes and the experiences of both healthcare consumers and providers. Under OCM, participants embraced the shift to more holistic, cost-conscious, person-focused care, resulting in better care for patients and resulted in consistently higher quality measure scores.
The most successful practices paired these changes with technical improvements including patient risk stratification, analytics for clinical and financial performance tracking and savings opportunity identification, care coordination and case management, and timely physician performance monitoring.
Access to relevant, comprehensive, and up-to-date data is always a predictor of success with value-based care. Speedy insight into individual patient risks allowed our providers to proactively work with patients to avoid hospitalizations or other adverse events, while a nuanced look into individual provider activities allowed leaders to make changes before performance periods close.
For these reasons, practices that plan to join EOM may wish to invest in technology platforms that offer access to critical data on a more timely basis instead of the typical 90-day or 120-day cycle to support more agile decision-making, and to combine claims data with clinical data from the EHR, lab, and pharmacy to enhance the accuracy and timeliness of insights and opportunities.
Provider groups should also carefully consider their own financial health when engaging in models like OCM or EOM. Conducting prospective financial modeling to predict likely performance is key for building confidence and pinpointing opportunities for improvement before committing to risk-based reimbursements.
Together, these tools and strategies make it much more likely that oncology groups can maximize the benefits of participating in value-based care initiatives moving forward.
How will EOM continue the value-based care journey for oncology practices?
OCM provides many valuable lessons for practices that hope to accrue financial rewards in EOM, and CMS has taken advantage of the past five years of learnings to fine-tune EOM’s clinical and financial features.
To start, CMS narrowed the scope of EOM, which includes just seven prevalent cancer types, all commonly treated with systemic chemotherapy. With the focus on breast cancer, chronic leukemia, lymphoma, multiple myeloma, prostate cancer, and small intestine/colorectal cancer, EOM will determine its target prices by using cancer type-specific price predictions.
This focuses costly resources on the cancers most likely to benefit and eliminates the MEOS payments from low-risk breast and prostate cancer cases, which require less effort and add to expense without creating much savings, thus making it easier for practices to realize shared savings.
CMS also increased the frequency of data reporting to better support agile decision-making. Under OCM, practices received claims data on a quarterly basis. In the new program, participants can request updates monthly to better guide their care delivery. This is a win for practices.
Additionally, CMS made changes to the benchmark calculation methodology. In OCM, some practices also found it difficult to compete against their own baselines, especially when those practices were highly efficient to begin with. EOM solves for this by introducing target price adjustments for regional and national cost variations. They have also attempted to clarify the attribution logic to make it easier for practices to know whether patients are eligible for the program.
EOM is also a mandatory two-sided risk program, with different savings hurdle options, and corresponding safety corridors and stop loss levels. Practices should carefully consider their capabilities and readiness to deliver on the requirements of the program and create efficiencies. Adoption of technology tools and knowhow will be keys to success.
EOM builds off the strong foundation of OCM and contains even more new components to support improved patient outcomes, but also to challenge participants to deliver high-quality care, including a spotlight on health equity and social determinants of health, the use of electronic patient reported outcomes (ePRO) data coming later down the road.
While these elements may be challenging for practices initially, especially with the lowered MEOS payments, they are likely to produce positive results in the long term for practices that have made an investment in practice transformation and value-based care infrastructure.
Practices can also leverage the same infrastructure for commercial payer APMs that have models similar to EOM or an Oncology Medical Home, which can result in more incentive payments and potential patient steerage. EOM is a promising opportunity for both graduates of OCM and new oncology providers that wish to participate in the value-based care environment. It also signifies the commitment of CMS and commercial payers to continue the transition to value-based care. For practices that have been on the sidelines thus far, EOM might be the call to join in.
By continually iterating on previous models and promoting involvement from the broader industry, we can create even more successful programs that meet the goals of reducing overall spending while adequately rewarding providers for their commitment to high-quality, coordinated cancer care. As the value-based care ecosystem evolves, we encourage CMS to continue working with commercial payers, employers, life science companies, and other stakeholders to bring value-based care opportunities to oncology practices.