Is the EOM DOA?

J Clin Pathways. 2023;9(5):69.

Value-based care is here to stay. Practices, patients, payers, and regulators are clamoring (and have been for decades) about the rising cost of health care, and multiple projects, both private and public, have done tremendous work to cre­ate a system that treats the entire patient while reducing the cost of care.

Independent, community oncology is no stranger to these initiatives; in July 2016, cancer care practices large and small joined the Oncology Care Model (OCM), the flagship value-based care model administered by the Center for Medicare and Medicaid Innovation (CMMI). The OCM wasn’t perfect, but practices were able to incorporate more advanced patient support and navigation structures, create partnerships with other providers, and reduce costs. Why, then, aren’t practices flocking to the OCM’s successor, the Enhancing Oncology Model (EOM)?

The EOM launched this past July, and the response from practices has been muted, at best. A survey of independent practices¹ conducted by the Community Oncology Alliance (COA) indicated that only 29% (40 practices) actually planned to participate in the model. The final tally of participating prac­tices announced a few weeks ago, 44, is a sharp contrast to the 122 practices that finished the OCM. What changed?

As it turns out, practices were warning CMMI all along: the COA survey also asked respondents to indicate why or why not they would be participating, and the top reasons listed for nonparticipation were the immediate assumption of two-sided risk arrangements, the unpredictability of the EOM and drug prices in the current market, and the reduc­tion of monthly enhanced oncology services (MEOS) pay­ments that reimburse participants for services covered under the EOM. CMMI could certainly have taken this stakeholder feedback and changed the EOM to accommodate the concerns of practices who wanted to be part of the vanguard of value-based care.

The EOM places a heavy emphasis on addressing social de­terminants of health (SDOH) to increase the overall wellness of patients. Addressing these factors is high on the list of every practice, but doing so requires significant investment in staff, tools, and training (as does just participating in a model like the EOM). Asking practices, especially ones that did not partici­pate in the OCM but wanted to join the EOM, to invest while assuming two-sided risk was too much of a gamble. Combine that with a reduced reimbursement rate for MEOS, and it’s no wonder that practices have avoided the EOM like the plague.

The unpredictability of EOM is compounded by major errors within the model. Before its launch, COA identified a significant flaw in the EOM’s breast cancer methodology that could cause practices to face an 8.3 percent greater drug spend than predicted, greatly increasing the chance of the practice incurring penalties under the two-sided risk arrange­ment. While CMMI was notified of the flaw, it still launched the EOM without a fix. Mistakes like this undermine confi­dence in the EOM and could have disastrous repercussions for participating practices.

More disconcerting is the prospect that CMMI seemingly isn’t required to ensure a certain level of statistically signifi­cant participation, or a population that is representative of our overall system of health care providers. We’re not even sure if there is anything in law or statute that requires this from CMMI models. This scenario is scary, because if CMMI deems a model to be a “success” in saving money, it can au­tomatically become wider Medicare policy without needing Congressional approval. How can we advance a new model of care on cancer providers if it hasn’t been adequately tested by the very providers expected to use it?

Leave no doubt: value-based care is the future. Successful models such as the OCM have shown that value-based care can improve the patient experience while reducing overall costs. This is exactly why CMMI should be required to test any care model it wants to advance on a statistically significant, repre­sentative, and diverse set of practices.

COA is dedicated to value-based care, and we support the mission of CMMI, even if we have had our disagreements. Just as we have supported participants in value-based care models in the past, we will support EOM participants. Our goal is to help transform our patient care for the better. However, COA will continue to advocate that CMMI do right by community oncology providers and the patients they serve.