Thanks to co-author Danny Costandy, a summer season affiliate in Foley’s San Diego workplace, for his contributions to this publish.
The Middle for Medicare and Medicaid Innovation (CMMI) is launching an extended awaited new oncology mannequin, the Enhancing Oncology Mannequin (EOM). EOM is a successor to the Oncology Care Mannequin (OCM), which ended June 30, 2020 after a five-year demonstration. EOM aligns with the targets of the Biden-Harris Administration’s Most cancers Moonshot Initiative, which seeks to enhance the expertise of individuals dwelling with most cancers, drive transformation in oncology care and advance well being fairness, whereas lowering Medicare spending.
Much like recently-ended OCM, EOM is a voluntary mannequin obtainable to all Medicare-enrolled doctor teams with no less than one oncology doctor or superior observe supplier that can run for 5 years starting on July 1, 2023. EOM incentivizes individuals to undertake a value-based and patient-centered method for Medicare fee-for-service beneficiaries receiving systematic chemotherapy over time and implement proactive care behaviors. Related with different CMMI innovation fashions like main care first (PCF) and direct supplier contracting (DPC), the Facilities for Medicare & Medicaid Providers (CMS) is encouraging doctor teams treating underserved populations to use. Additional, personal payers and state Medicaid businesses are inspired to align with EOM.
As famous beneath, EOM necessities construct upon OCM necessities. Not like OCM, all EOM individuals shall be uncovered to down-side threat. Accordingly, we anticipate OCM practices that acquired efficiency funds within the one-sided mannequin or succeeded below the two-side threat mannequin in OCM will apply to take part in EOM.
All qualifying doctor teams can now apply to take part in EOM by way of September 30, 2022. As with many different innovation fashions, accepted candidates will elect to take part after receiving a participation settlement from CMS.
EOM and OCM – Similarities and Variations
Much like OCM, EOM will make use of six-month care episodes and necessities for enhanced providers, month-to-month funds, and performance-based funds based mostly on high quality of providers carried out.
- Episode-based fee will drop from the OCM’s $160 to the EOM’s $70.
- Contributors in EOM can select to invoice for a month-to-month enhanced fee of $70 for every beneficiary (and $30 extra per thirty days for dual-eligible sufferers).
EOM individuals can choose from two threat preparations that each contain draw back threat – a reasonable threat profile that’s anticipated to qualify as a CMS Benefit-based Incentive Fee System (MIPS) various fee mannequin (APM) and a extra aggressive threat profile that can qualify as a MIPS APM and an Superior APM. Contributors might swap between the 2 threat preparations between efficiency years. OCM provided a one-side threat association that certified as a MIPS APM and a two-sided threat association that certified as an Superior APM.
Nevertheless, EOM can have fewer qualifying beneficiaries than OCM however have a higher potential for cost-reduction. OCM included almost all beneficiaries receiving systemic chemotherapy or hormonal remedy for all most cancers varieties. In distinction, EOM is proscribed to beneficiaries receiving systemic chemotherapy for seven most cancers varieties:
- breast most cancers;
- continual leukemia;
- small gut/colorectal most cancers;
- lung most cancers;
- lymphoma;
- a number of myeloma; and
- prostate most cancers.
Much like OCM, EOM would require individuals to implement the next:
- Provide 24/7 entry to an applicable clinician with real-time entry to affected person information;
- Present affected person navigation;
- Doc a care of plan;
- Make the most of information for high quality enchancment;
- Meet high quality measures (e.g., affected person expertise, acute care utilization, symptom and toxicity administration, administration of psychosocial well being, palliative care administration).
Not like OCM, EOM will moreover require individuals to display screen for health-related social wants; report affected person demographic information (e.g., race, ethnicity, language, gender establish); develop plans exhibiting how individuals will use evidence-based methods to handle well being fairness gaps of their affected person populations; and can slowly implement digital affected person reported outcomes. For the latter actions, individuals’ use of knowledge for high quality enhancements which shall be constantly supported by suggestions stories from CMS that can assist EOM establish disparities amongst its affected person inhabitants.
Much like how OCM individuals benefited from relaxed telehealth and home-based care below the Public Well being Emergency waivers, CMS is waiving sure Medicare fee necessities for EOM individuals and increasing their patient-centered care administration toolbox.
- Telehealth profit enhancement permits telehealth go to from any location to beneficiaries as a substitute of requiring journey to a well being care facility.
- Publish-discharge profit enhancement permits as much as 9 post-discharge residence visits by auxiliary workers inside 90 days of discharge below normal supervision (not direct supervision) of a doctor or different certified practitioner.
- Care administration residence go to profit enhancement permits residence visits by auxiliary workers below normal supervision (not direct supervision) of a doctor or different certified practitioner upfront of potential hospitalization.
Former OCM individuals, together with practices who sat out participation in OCM or joined different innovation fashions, concerned with participation in EOM, ought to fastidiously assess if and the way they’ll adapt to efficiently take part within the new mannequin.
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