Enhancing Oncology Model

The Enhancing Oncology Model (EOM) aims to drive transformation and improve care coordination in oncology care by preserving and enhancing the quality of care furnished to beneficiaries undergoing treatment for cancer while reducing program spending under Medicare fee-for-service. Under EOM, participating oncology practices will take on financial and performance accountability for episodes of care surrounding systemic chemotherapy administration to patients with common cancer types. EOM is a 5-year voluntary model, beginning on July 1, 2023, that aims to improve quality and reduce costs through payment incentives and required participant redesign activities. CMS designed EOM to test how to improve health care providers’ ability to deliver care centered around patients, consider patients’ unique needs, and deliver cancer care in a way that will generate the best possible patient outcomes.

EOM supports President Biden’s Unity Agenda and Cancer Moonshot initiative to improve the experience of people and their families living with and surviving cancer. EOM aligns with the Cancer Moonshot pillars and priorities of supporting patients, caregivers, and survivors, learning from all patients, targeting the right treatments for the right patients, and addressing inequities.

Highlights
  • Patients who receive a diagnosis of cancer may feel overwhelmed with the information they are given from their oncologists (cancer doctors). Patients may be hesitant to ask questions about the treatment plan, including cost and expected outcome of treatment. Additionally, these patients may find themselves responsible for coordinating care between their cancer specialists and their primary care doctor, and may be unclear or uncertain on how to manage side effects of treatment.
  • The Enhancing Oncology Model (EOM) aims to improve coordination across all of a cancer patient’s health care providers and supports personalized services that help the patient navigate and manage their cancer care. EOM participants take into consideration their patients’ preferences and goals for treatment, health-related social needs, such as housing and transportation assistance, as well as psychosocial health needs.
  • The goal of EOM is for patients to feel better supported in their care; have a clearer understanding of their diagnosis, prognosis and expected outcomes; and be able to adhere to their treatment plan which they develop in partnership with their oncologist.
  • EOM provides additional support to participants who treat underserved or lower-income patients, specifically those who are dually eligible for Medicare and Medicaid. The additional supports aim to lead to improved access, treatment, and outcomes for these beneficiaries.

Background

CMS announced the Oncology Care Model (OCM) in February of 2015, and OCM subsequently launched on July 1, 2016, with an end date of June 30, 2022. In the last six years, OCM incentivized practitioners to improve the way in which they provide cancer care to focus on the patient, improve or maintain quality, and avoid unnecessary costs. Similar to OCM, EOM will focus on value-based, patient-centered care for cancer patients undergoing chemotherapy based on 6-month episodes of care, with a specific focus on health equity. EOM builds on lessons learned from OCM and feedback from the oncology community, including OCM participants, patient advocacy groups, oncology professional associations, and others to further advance the journey in value-based care in oncology.

Information for EOM Participants  

CMS published a Request for Application (RFA) for the Enhancing Oncology Model on June 27, 2022. CMS has determined that the anti-kickback statute safe harbor for CMS-sponsored model arrangements (42 CFR § 1001.952(ii)(1)) will be available, beginning July 1, 2023, to protect certain “pooling arrangements” (as described in Section VII.B.ii. of the RFA) between or among one or more EOM participants, and certain Care Partner Arrangements (as discussed in section VII.B.i. of the RFA) between an EOM participant and its Care Partners, provided that such arrangements comply with the requirements of the safe harbor and the requirements to be set forth in the EOM participation agreement.  

Further, CMS has determined that the anti-kickback statute safe harbor for CMS-sponsored model patient incentives (42 CFR § 1001.952(ii)(2)) is available to protect certain in-kind patient incentives furnished by an EOM participant, EOM practitioner, or Care Partner to an eligible beneficiary, as discussed in section VIII.M. of the RFA, provided that such incentives are furnished in a manner that complies with the requirements to be set forth in the EOM participation agreement. 

The terms EOM participant, EOM practitioner, Care Partner, Care Partner Arrangements, and eligible beneficiary are described in the RFA and will have the meanings that will be set forth in the EOM participation agreement.
 

Information for Medicare Beneficiaries

The central goal of EOM is to better support patients and improve their care experience, advancing a key goal of the Cancer Moonshot Initiative. You will not be responsible for paying for any portion of the new EOM payment for participants’ delivery of enhanced, patient-focused services. Medicare will cover the full amount of this payment.

As a patient whose health care providers are participating in EOM, you may communicate better with your oncologist and care team in between appointments and be able to more easily reach them with questions. You may also expect to receive enhanced, patient-focused services, such as:

  • 24/7 access to an appropriate clinician with real-time access to your medical records;
  • Patient navigation services; 
  • A detailed care plan that involves your engagement and preferences on discussions surrounding prognosis, treatment options, symptom management, quality of life, and psychosocial health needs, among other topics;
  • Screening for health-related social needs (HRSNs); (needs related to food, transportation, housing, etc.);
  • Questions regarding your overall cancer care experience and health outcomes, such as those related to your symptoms, physical functioning, behavioral health, and HRSNs.

Patients retain their freedom to choose any provider or supplier, and may also choose for their data not to be shared with EOM participants. If a patient or their caregiver feels care has been compromised or has concerns about EOM, the Innovation Center has a model liaison that is a part of the Medicare Beneficiary Ombudsman team in the Office of Hearings and Inquiries. The model liaison can be reached through 1-800-MEDICARE or they may contact their Quality Improvement Organization (QIO).

Model Details

The goals of EOM are to:

  • Put the patient at the center of a care team that provides equitable, high-value, evidence-based care; 
  • Build on OCM lessons learned and continue the value-based journey in oncology, which is a historically high-cost area of Medicare spending; 
  • Increase engagement of patients, oncologists, and other payers (e.g., state Medicaid agencies, commercial payers) in value-based care and quality improvement; and,
  • Observe improved care quality, health equity, and health outcomes as well as achieve savings over the course of the model test.

To achieve these aims, EOM employs the following design elements:

  • Comprehensive, coordinated cancer care; 
  • Continuous improvement driven by data; 
  • Payment incentives including a Monthly Enhanced Oncology Services (MEOS) payment, and a performance-based payment (PBP) or a performance-based recoupment (PBR); 
  • An aligned multi-payer structure; and
  • Focused efforts to identify and address health disparities.

EOM participants assume accountability for their patients’ health care quality and for their spending on care over time. EOM gives participants opportunities to redesign care and improve the quality of care given to beneficiaries receiving systemic chemotherapy for seven cancer types: breast cancer, chronic leukemia, small intestine/colorectal cancer, lung cancer, lymphoma, multiple myeloma, and prostate cancer.

Under EOM, participants are incentivized to consider the whole patient and engage with them proactively, during and between appointments. EOM participants are required to implement participant redesign activities, including 24/7 access to care, patient navigation, care planning, use of evidence-based guidelines, use of electronic Patient Reported Outcomes (ePROs), screening for health-related social needs, use of data for quality improvement, and use of certified electronic health record technology. As part of the use of data for quality improvement, participants will submit health equity plans to CMS, where EOM participants will detail their evidence-based strategies to mitigate health disparities identified within their beneficiary populations.

EOM implements a two-part payment structure for EOM participants to incentivize the provision of Enhanced Services while creating incentives to reduce avoidable costs and utilization and improve care quality. EOM participants will be responsible for the total cost of care during a 6-month episode. Depending on total episode expenditures and quality performance, EOM participants have the potential to earn a performance-based payment (PBP) or owe CMS a performance-based recoupment (PBR). PBP and PBR amounts will be adjusted based on actual quality performance. EOM participants will also have the option to bill a Monthly Enhanced Oncology Services (MEOS) payment per beneficiary per month for the provision of Enhanced Services to EOM beneficiaries during each 6-month episode. EOM includes an additional MEOS payment for dually eligible beneficiaries, acknowledging the greater resources that may be needed to care for complex and underserved communities.

Please see the Request for Application for more information on the design of EOM. In addition, a detailed payment methodology paper has been published for EOM in the summer, and is linked below in the Technical Documents section.

MIPS Payment Adjustment Exception Applicable for EOM MEOS Payments

A notice has been published in the Federal Register to inform potential EOM applicants and participants that the Merit-based Incentive Payment System (MIPS) payment adjustment factors will not apply to MEOS payments in EOM. For   more information, please find the Federal Register Notice here: https://www.federalregister.gov/public-inspection/2022-15062/medicare-program-merit-based-incentive-payment-system-payment-adjustment-exception-applicable-for

Events

Additional Information

Technical Documents

 

Outreach

If you are interested in receiving additional information, updates or have questions about the EOM Model, please engage with the below resources:

 

Last updated on:
05/31/2023