The OCM was a 5-year voluntary advanced payment model that the Centers for Medicare and Medicaid Services (CMS) developed through the Innovation Center (CMMI) beginning July 1, 2016. CMS changes to advanced payment models due to the COVID-19 Public Health Emergency turned it into a 6-year model, which ended June 30, 2022.
The model aimed to reduce Medicare payments, improve beneficiaries’ care, and save taxpayer money by supporting coordinated, high-quality, cost-effective cancer care.
OCM featured a two-pronged financial incentive. First, practices could bill Medicare for a $160 Monthly Enhanced Oncology Services (MEOS) fee per beneficiary per month (PBPM) for the required care coordination and enhanced service. CMMI also tied a performance-based payment (PBP) incentive to the practice’s total episode costs against benchmarks for the practices in each six-month Performance Period (PP).
CMMI collaborated with participating practices and the Community Oncology Alliance (COA) to gather participant feedback and modify the model on patient attribution and metrics, while delivering punctual feedback to allow practices to enact timely adjustments. Some practices never earned performance-based incentives despite making practice transformation changes to their care delivery.
A December 2021 report revealed that OCM led to $377.1M in net losses for Medicare through PP 1-5. While drug costs were similar between model and comparator practices, participants achieved savings by adopting supportive care and biosimilar drugs. CMS attributed its financial losses to the MEOS payments. At its conclusion, there were just 126 practices and five commercial payer participants, down from the baseline period of 195 and 17, respectively. Some attrition was related to consolidation or unwillingness to take on downside risk.
This June, CMS announced the Enhancing Oncology Model (EOM) to drive transformation and cost-savings in oncology care for beneficiaries undergoing treatment for seven types of cancer. It aligns with the Biden Administration’s priorities for health equity and Cancer Moonshot.
Like OCM, EOM emphasizes cross-payer alignment, guideline concordance, and addressing and reporting health inequities. Drugs are paid (based on ASP) and included in total episode cost calculations. However, oncology practices must take on financial risk and receive reduced MEOS payments, $70 PBPM compared to $160 PBPM in the OCM model. EOM reduces the number of cancers and therapies and includes Medicare/Medicaid dual eligible members.
The new model does not begin for another year (July 1, 2023), leaving a year-long gap for OCM practices that have invested in building practice infrastructure and care coordination teams and no longer able to be compensated via the MEOS billing code.
Potential Implications and Opportunities:
The implications and opportunities differ by stakeholder, and we believe these will continue to evolve over the next 6-9 months as we gain greater clarity from CMS.
Will providers sign on given the gap year between models?
· How long will practices be able to continue providing enhanced services and support the infrastructure they invested in for OCM without the MEOS payments?
Of concern is whether OCM practices will be able to afford to offer OCM-type services outside of a model or need to change their service approach.
· Will OCM practices continue services and start billing for CCM?
OCM included a claims edit so practices billing a MEOS code were not able to also bill a chronic care management (CCM) code. EOM lowers MEOS payments by more than half to $70 for FFS patients and $100 PBPM for dually eligible members. Practices can now bill for enhanced services provided under the CCM code outside the model, around $64. The burden of new reporting requirements and downside risk may not be attractive for practices.
· Will provider group practices apply to participate in the model by September 30, 2022?
As a financial risk-only model, OCM practices that did well in terms of PBP are likely to engage in the EOM. However, about 50% of physician groups did not receive a PBP in OCM through PP6. Will these practices engage?
· How many practices signing on continue to the Memorandum of Understanding stage in late 2022/early 2023?
We believe practices will apply, allowing time to gather more information before entering the binding CMS agreement.
· What will the practice mix look like across community and academic/hospital providers?
The model aims to address disparities in care associated with social determinants, particularly in the Medicare/Medicaid dually eligible population. The higher $100 PBPM MEOS payment may make EOM more attractive to health systems and hospital clinics that may be treating these patients as part of their classification as Disproportionate Share Hospitals (DISH) under the Federal 340B Drug Pricing Program. The higher MEOS payment incentivizes facilities rather than community oncology practices, which tend to treat fewer dual eligible patients
How will payers respond?
· At the end of OCM, only five commercial payers remained in the model, with Aetna and Cigna being large national payers likely to engage.
· Payers with significant MA populations, particularly regional plans, may find EOM participation attractive given the need to align with only one provider group practice.
What are the benefits and risks for patients?
· Expansion to the dually eligible population and Medicare Advantage and Commercial payers will expand the patients receiving high-value care; however, this is only for the seven included cancers.
· Practices billing for enhanced care under the CCM code may subject patients to added cost sharing, contributing to financial stress.
How should manufacturers proceed?
· Pharmaceutical companies can provide input to CMS based on their unique perspective and customer feedback.
· Manufacturers must understand EOM’s key features concerning how it impacts its customers. There may be educational opportunities to support practices and payer stakeholders interested in education on best practices.
· Manufacturers with drug therapies in the 7 included cancer types will want to evaluate the potential impact across demand and access factors and how their therapeutic products may be advantaged or disadvantaged based on the rotating drug lists CMS will provide each PP. This impact will be significant for drug classes with lower-cost treatments available.
- https://innovation.cms.gov/data-and-reports/2021/ocm-ar4-eval-payment-impacts Accessed July 18, 2022
- https://www.cms.gov/files/document/covid-innovation-model-flexibilities.pdf Accessed July 18, 2022
- https://www.hhs.gov/about/news/2022/06/27/biden-administration-announces-new-model-to-improve-cancer-care-for-medicare-patients.html Accessed July 18, 2022